Ileostomy formation does not prolong hospital length of stay after open anterior resection when performed within an enhanced recovery programme.

AIM: Previous studies have implicated stoma formation as an independent factor prolonging length of stay (LOS) after colorectal surgery. We examined whether loop ileostomy (LI) formation during an open anterior resection affected LOS within a newly developed enhanced recovery programme (ERP). This involved reorganization of services, including stoma care, to optimize pre- and perioperative patient education, training and expectation, while applying the standard scientific principles of enhanced recovery. METHOD: Data were collected prospectively on 72 consecutive open anterior resections (33 with LI) to see whether LI affected LOS. Stomas were fashioned at the surgeon's discretion and patients were discharged according to agreed criteria. RESULTS: Thirty-three of the 72 patients had a covering LI performed. The overall age range was 32-85 years (median 68), with 40 patients being men. LOS for all 72 patients ranged from 3 to 34 days. The median and mean LOS were the same for both groups (median 6 days, mean 8 days). The complication rate was 44% (32/72) with a leak rate of 7% (5/72) and a mortality of 1.4% (1/72). Between the two groups (no ileostomy vs ileostomy), there was no statistically significant difference in complications (41%vs 48%), leakage (8%vs 6%) and readmission rates (12%vs 5%). CONCLUSION: A covering loop ileostomy need not prolong hospital stay after open anterior resection.

A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure.

BACKGROUND: Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF. METHODS: The recorded outcomes of CAF following treatment with the two methods were analysed retrospectively. Patients underwent either fissurectomy followed by injection of 40 U BTA into the internal sphincter (group A) or fissurectomy followed by the perianal application of DTC twice daily for 8 weeks (group B). Symptom resolution and treatment side effects at the initial follow-up were compared. RESULTS: Demographics, fissure characteristics and the number of multiparous women between the two groups were comparable. At a median follow-up of 12 weeks (range 8-20 weeks), the two groups had similar rates of complete symptom resolution (group A, 25/28, 89.3%; group B, 19/23, 82.6%; p=0.7739), with minor side effects. CONCLUSIONS: In this small pilot study fissurectomy combined with chemical sphincterotomy resulted in high short-term fissure healing rates. The study also suggested that fissurectomy followed by 8 weeks of topical DTC may be as good as fissurectomy with BTA injection in the treatment of CAF. A prospective study, adequately powered to determine the significance of differences is needed.

Combined modality treatment of early rectal cancer: the UK experience.

With the introduction of colorectal screening in the UK, more patients will probably be diagnosed with early rectal cancer. The UK has an increasingly elderly population and not all patients diagnosed with early rectal cancer will be suitable for radical surgery. Therefore, a national plan is needed to develop the provision of alternative local treatment with equity of access across the country. Here we review the Clatterbridge Centre for Oncology multimodality treatment policy, which has been in clinical practice since 1993 and we discuss its rationale. Clatterbridge is the only centre in the UK offering Papillon-style contact radiotherapy. In total, 220 patients have been treated over 14 years, most of whom were referred from other centres. One hundred and twenty-four patients received Papillon (contact radiotherapy) as part of their multimodality management. The guidelines of the Association of Coloproctology of Great Britain and Ireland recommend local treatment for T1 tumours<3 cm in diameter, but this refers to treatment by surgery alone. There are no published national guidelines for radiotherapy. We plan each treatment in stages and achieve excellent local control (93% at 3 years) with low morbidity. We conclude that radical local treatment for cure can be offered safely to carefully selected elderly patients. Close follow-up is necessary so that effective salvage treatment can be offered. Because of a lack of randomised trial evidence, at present local radiotherapy is not yet accepted as an alternative option to the gold standard surgical treatment. Even with international collaboration, a randomised trial will be difficult to complete as the number of cases requiring local radiotherapy is small due to the highly selective nature of the treatment involved. However, an observational phase II trial is planned. In addition, the Transanal Endoscopic Microsurgery Users Group is also planning a phase II trial using preoperative radiotherapy. These studies will provide evidence to help establish the true role of radiotherapy in early rectal cancer.

Postoperative arrhythmias in colorectal surgical patients: incidence and clinical correlates.

OBJECTIVE: To determine the incidence and clinical correlates of postoperative cardiac arrhythmias in patients undergoing elective large bowel resection. METHODS: Fifty-one consecutive patients undergoing elective open colorectal resection were recruited for this prospective observational study. Participating patients underwent daily three-lead electrocardiograms postoperatively. Data regarding potential risk factors for arrhythmias were recorded. Post-operative complications were recorded. RESULTS: Thirteen (26%) patients developed a postoperative arrhythmia, most commonly atrial fibrillation. Significant univariate correlates with postoperative arrhythmias were: age (P<0.01), hypertension (P<0.01), pre-operative serum potassium levels (P<0.01), postoperative pulmonary oedema (P=0.03), postoperative serum potassium (P=0.03) and sodium (P<0.01). Arrhythmia patients were more likely to have other complications (P=0.02). Thirty-one percent of arrhythmia patients had underlying sepsis compared with 18% of controls (P=0.38). CONCLUSION: Arrhythmias are common following elective large bowel resection. They occur in older patients and are associated with the development of other complications.

Multi-modality approach in curative local treatment of early rectal carcinomas.

OBJECTIVE: Despite recent advances, surgery remains the mainstay for the management of rectal carcinoma. The conventional surgical treatment for low rectal carcinoma is total mesorectal excision. This results in either abdomino-perineal excision of the rectum (APER) with permanent colostomy or low anterior resection (LAR) usually with a covering stoma. Local resection is an alternative treatment option and this could be offered either using manual trans-anal resection (TAR) or transanal endoscopic microsurgery (TEM) if the tumour is situated higher. PATIENTS: Patient selection is an important factor if local resection is used. No further treatment is necessary for T1 tumours with clear surgical resection margins. Conventional radical surgery should be offered for T1 tumours with close resection margins (<1 mm) or T2 tumours with higher risk of lymph node metastases. Patients were treated by postoperative chemo-radiotherapy or radiotherapy, if further radical surgery was not considered appropriate or if the patient refused further surgery. Using this approach, we describe our experience of 100 patients treated from January 1992 to June 2002. RESULTS: Only 13 patients had surgery alone and 87 patients had radiotherapy either pre-operative (33 patients), postoperative (25 patients) or radical radiotherapy alone (29 patients). Local recurrence occurred in 10% of patients and salvage surgery was offered in over half (6 patients) of these patients. At median follow up of 33 months (range 3-120 months), the overall survival was 77% reflecting the fact that the majority of these patients were elderly with coexisting medical problems. However, cancer specific survival was 96%. More importantly, only 9 patients had colostomies and colostomy-free survival in our cohort of patients from Liverpool was 91%. CONCLUSION: We concluded that in selected patients, who were not medically fit (ASA 111 or above) or those who were unable to accept a permanent colostomy, local treatment could be offered with curative intent using a multimodality approach. In our experience, relapses can be salvaged effectively and we recommend a long-term close follow up policy.

Randomised trial of octreotide for long term management of cirrhosis after variceal haemorrhage.

OBJECTIVE: To assess the efficacy of long term octreotide as adjuvant treatment to programmed endoscopic sclerotherapy after acute variceal haemorrhage in cirrhotic portal hypertension. DESIGN: Randomised clinical trial. SETTING: University hospital. SUBJECTS: 32 patients with cirrhotic portal hypertension. INTERVENTIONS: Programmed injection sclerotherapy with subcutaneous octreotide 50 micrograms twice daily for 6 months, or programmed injection sclerotherapy alone. MAIN OUTCOME MEASURES: Episodes of recurrent variceal bleeding and survival. RESULTS: Significantly fewer patients receiving combined octreotide and sclerotherapy had episodes of recurrent variceal bleeding compared with patients given sclerotherapy alone (1/16 v 7/16; P = 0.037, Fisher's exact test), and their survival was significantly improved (P < 0.02, log rank test); this improvement was maintained for 12 months after the end of the study. Combined treatment also resulted in a sustained decrease in portal pressure (median decrease -6.0 mm Hg, interquartile range -10 to -4.75 mm Hg, P = 0.0002) compared with sclerotherapy alone (median increase 1.5 mm Hg, interquartile range 0.25 to 3.25 mm Hg), as well as a significant improvement in liver function as assessed by plasma concentrations of bilirubin, albumin, and alanine aminotransferase and by hepatocyte metabolism of aminopyrine labelled with carbon-14. CONCLUSION: Long term octreotide may be a valuable adjuvant to endoscopic sclerotherapy for acute variceal haemorrhage in cirrhotic portal hypertension.

Making the new deal for junior doctors happen.

How can the new deal for juniors be implemented in today's overstretched health service? How do you get clinicians and management to work together? On the Wirral falling house officer morale and recruitment stimulated a new approach, action learning, which proved to be highly successful. Action learning is not a new approach in management terms, but it is rarely used in the health service. Guided by an experienced facilitator, a group of people learn management skills by exploring and resolving practical problems relevant to them. A group of general practitioners and consultants used action learning to teach themselves more about management and at the same time to make changes which addressed many of the junior doctors' difficulties and solved the hospital recruiting problem.

A new enzyme-linked lectin/mucin antibody sandwich assay (CAM 17.1/WGA) assessed in combination with CA 19-9 and peanut lectin binding assay for the diagnosis of pancreatic cancer.

BACKGROUND: Mucus glycoproteins are often present in the sera of patients with pancreatic cancer, and their detection and quantification can be used in serologic diagnosis. METHODS: A novel enzyme-linked "sandwich" assay (CAM 17.1/WGA) has been developed in which a lectin, wheat germ agglutinin (WGA), is bound to the solid phase to capture serum glycoproteins, and after addition of test sera, a monoclonal antimucin antibody (CAM 17.1) and peroxidase-tagged second antibody are used as a detection system. RESULTS: The test has been applied to sera from 79 patients with pancreatic cancer and 120 controls. The CAM 17.1/WGA assay alone had a sensitivity of 78% and specificity of 76% in the diagnosis of pancreatic cancer. Combination of the CAM 17.1/WGA test with a previously described peanut lectin binding assay (PNA/ELLA) provided a sensitivity of 92% and specificity of 70%, whereas combination of the CAM 17.1/WGA assay with the CA 19-9 radioimmunoassay had a sensitivity of 85% and specificity of 76%. Combination of all three tests had a sensitivity of 94% and specificity of 66%. In nonjaundiced patients, the combination of CAM 17.1/WGA and PNA/ELLA had a sensitivity of 93% and specificity of 79% in the diagnosis of pancreatic cancer. CONCLUSIONS: This new test adds significantly to the armamentarium of serologic tests for pancreatic cancer. These tests are particularly effective when used in combination to detect different mucin-borne carbohydrate antigens. They deserve more widespread use, particularly in examining nonjaundiced patients with unexplained abdominal pain or weight loss.

A prospective randomised controlled trial comparing the efficacy of somatostatin with injection sclerotherapy in the control of bleeding oesophageal varices.

Since previous reports have suggested that somatostatin may be of value in the control of acute variceal haemorrhage, we compared its efficacy with that of injection sclerotherapy in a randomised controlled clinical trial. Eighty consecutive patients with endoscopically-proven severe variceal bleeding were randomised to injection sclerotherapy (n = 41) or somatostatin (n = 39) given as a continuous infusion of 250 micrograms/h for 5 days plus daily bolus administration of 250 micrograms. The efficacy of injection sclerotherapy and somatostatin infusion in controlling haemorrhage and preventing rebleeding (censored at 5 days), mortality (censored at 28 days) and complications was compared. The aetiology of the portal hypertension and transfusion requirements was similar between the two groups, but there were more patients with severe liver disease (Child's C) in the somatostatin group. There was no significant difference between the two treatments in the initial (p = 1.0) or overall control of bleeding (p = 0.58). Furthermore, somatostatin was as effective as injection sclerotherapy in controlling bleeding in patients with severe liver disease or in those actively bleeding at the time of their endoscopy. The relative risk of rebleeding whilst receiving somatostatin compared to injection sclerotherapy was 1.39 [95% Confidence Interval (CI) 3.73; 0.52], but this was reduced to 0.98 (95% CI 0.37; 2.67) when readjusted for Child's grading, the only prognostic factor shown to be of significance. Mortality was not significantly different between the two groups of patients (p = 0.31). The relative risk of dying whilst receiving somatostatin compared to injection sclerotherapy was 1.6 (95% CI 3.93; 0.66) but was reduced to 1.03 (95% CI 0.47; 2.47) when adjusted for Child's grading, the only significant prognostic factor. Complications in the somatostatin group were minor and less frequent than after injection sclerotherapy. The results of this study indicate that somatostatin is a safe treatment, which is as effective an endoscopic injection sclerotherapy for acute variceal bleeding.

Over-utilisation of radiography in the assessment of stapled colonic anastomoses.

We have reviewed the radiological studies in 31 patients who underwent stapled colorectal anastomoses using the EEA staple gun. In 10 patients there was clinical evidence to suggest anastomotic dehiscence. Nine of these patients had a disrupted staple ring on plain abdominal radiograph. In these days of audit and financial constraint, we suggest that radiological investigation should be reversed for those patients with questionable clinical evidence of an anastomotic leak.

Prospective study of the serosubmucosal (extramucosal) suture technique for gastrointestinal anastomosis.

Seventy gastrointestinal anastomoses were constructed in 52 patients using a single layer of interrupted sutures placed in the serosubmucosal or extramucosal layer. Gastric anastomoses (n = 16) were performed by a partly open method, small bowel and colonic anastomoses (n = 44) by a closed method, and colorectal anastomoses (n = 10) by an open method. Wound infection occurred in two patients (3.8%) and three patients died (5.8%). Anastomotic leakage in four patients (7.7%) arose from three ileocolic anastomoses and one colorectal anastomosis. The third leak from an ileocolic anastomosis resulted in death and necessitated termination of the study on ethical grounds. There were two other postoperative deaths from cardiorespiratory causes (3.8%). The serosubmucosal or extramucosal technique is safe and effective (leak rate 1 of 26; 3.8%) when performed by the partly open or open method for gastric and colorectal anastomoses. However, when constructed by the closed method a relatively high leakage rate (3 of 44; 6.8%) occurs in anastomoses (ileocolic) generally associated with a low morbidity.

Can immunohistology improve detection of lymph-node metastases in large-bowel cancer?

Employing the monoclonal antibody CAM5.2, the sensitivity of immunohistologic staining was compared with conventional hematoxylin and eosin staining for detection of lymph-node metastases from large-bowel cancer. Ten patients who died unexpectedly early from recurrent disease were selected; 86 lymph nodes were examined. Where metastases were located they were readily identified by both methods but when the original lymph-node sections were reviewed, attention was drawn to two metastatic deposits that had been overlooked previously. These results suggest that immunohistologic techniques offer no advantage in the identification of lymph-node metastases in large-bowel cancer.

Monoclonal antibodies raised to colorectal carcinoma antigens.

The search for tumour markers was intensified with the advent of monoclonal antibody technology. To date no tumour specific markers have been found. Despite this, monoclonal antibodies have helped to identify cells in terms of their origin and function and therefore added a different dimension to studies of both benign and malignant disease processes. Advances in molecular biology have made cooperation between scientists and clinicians in all branches of medicine essential in order to piece together a more complete picture of any disease. This article describes the production and characterisation of two epithelial specific monoclonal antibodies (CAM5.2 and CAM17.1) with potential clinical value by a surgeon temporarily transposed to a laboratory environment.

Epithelial markers in thyroid carcinoma: an immunoperoxidase study.

Ten cases each of papillary, follicular, anaplastic and medullary carcinoma of the thyroid were stained for thyroglobulin, calcitonin, epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA) and cytokeratin (CAM 5.2). Monoclonal or affinity purified polyclonal antibodies, and an indirect immunoperoxidase technique were used. All the papillary and follicular tumours, 5/10 anaplastic and 3/10 medullary carcinomas contained thyroglobulin. Only the 10 medullary carcinomas stained positively for calcitonin. Three out of 10 papillary, 1/10 follicular, 0/10 anaplastic and 10/10 medullary carcinomas were positive for CEA. Nine out of ten papillary, 7/10 follicular, 2/10 anaplastic and 3/10 medullary carcinomas were positive for EMA. Ten out of 10 papillary, 10/10 follicular, 5/10 anaplastic and 10/10 medullary carcinomas were positive for cytokeratin. The presence of calcitonin and CEA is of value in the diagnosis of medullary carcinoma, and enable its distinction from anaplastic thyroid carcinoma. Thyroglobulin is a useful marker in thyroid carcinomas.

Expression of low molecular weight cytokeratin proteins in cervical neoplasia.

CAM 5.2 is a monoclonal antibody which identifies lower molecular weight cytokeratin proteins (50, 43 and 38 kD). It is an antibody which works reliably on formalin-fixed, paraffin-embedded tissues. In this study, using CAM 5.2 in the indirect immunoperoxidase method we have examined ectocervical epithelium ranging from normal, through metaplasia and cervical intraepithelial neoplasia to invasive squamous carcinoma. CAM 5.2 is demonstrated to be a useful indicator of changes associated with malignant transformation in the ectocervix.