Colonic pouchography is not routinely required prior to stoma closure.

BACKGROUND: Colonic pouch formation with pouch-anal anastomosis is now regarded as the procedure of choice for restoration of intestinal continuity following anterior resection for low rectal cancers. The aim of this study was to review the necessity for routine colonic pouchography prior to closure of a diverting loop stoma. METHODS: This was a prospective study of 52 consecutive patients who underwent colonic pouch formation between 1 June 1999 and 31 May 2002, four of whom have subsequently died. Each pouch was assessed clinically and radiologically prior to stoma closure. RESULTS: There were no clinical anastomotic leaks. Forty-six of 48 surviving patients have had a colonic pouchogram and in no case was either a pouch or pouch-anal anastomotic defect identified. To date 40 patients have undergone stoma closure without an anastomosis-related complication. CONCLUSION: Following successful colonic pouch formation, routine study of the pouch by contrast radiology does not add to clinical assessment. As a consequence radiological imaging is unnecessary and can be omitted.

Non-restorative surgery for rectal cancer: indications in 2003.

BACKGROUND: Although the majority of patients with low rectal tumours can now be offered restorative surgery, a subset of patients with very distal, locally extensive tumours, or excessive comorbidity, continue to require abdominoperineal resection or a Hartmann's procedure. The Clinical Standards Board for Scotland (CSBS) recommends that the permanent stoma rate for patients with rectal cancer should be no more than 40%. The aim of this study was to determine the proportion of patients not suitable for restorative surgery and to explore the remaining indications for non-restorative surgery. MATERIALS AND METHODS: Data pertaining to the management of 100 consecutive patients treated for a rectal adenocarcinoma were extracted from a prospective database. RESULTS: Eighty-one patients underwent primary restorative surgery; 12 patients, 9 of whom had received neoadjuvant therapy, had abdominoperineal excision for low rectal or anorectal tumours. Seven patients with locally extensive disease underwent an unplanned Hartmann's procedure rather than high anterior resection. Two of these resections were incomplete and two patients had metastatic disease not detected on staging. CONCLUSION: Not all patients with rectal cancer can avoid the formation of a stoma, but our results show that more than 80% of patients can be offered primary restorative surgery. The CSBS guidelines do not reflect acceptable contemporary practice and should be revised. This is particularly pertinent with the likely introduction of population screening for colorectal cancer.

Right hemicolectomy: mechanical bowel preparation is not required.

BACKGROUND: Mechanical bowel preparation before colonic surgery is widely advocated but remains controversial. Recent guidelines published by the Clinical Standards Board for Scotland recommend mechanical bowel preparation prior to surgery for all colorectal cancers but this may be inappropriate. This study examines the outcome of a policy of no mechanical preparation before elective right hemicolectomy. METHOD: Data on 102 consecutive patients undergoing elective right or extended right hemicolectomy for colonic adenocarcinoma were extracted from a prospective database. RESULTS: No clinical anastomotic leaks were observed. Two patients developed wound infections and one patient died with no autopsy evidence of anastomotic leak. CONCLUSION: Mechanical bowel preparation can safely be omitted prior to right hemicolectomy in patients with colonic cancer.

Optimum method for urinary drainage in major abdominal surgery: a prospective randomized trial of suprapubic versus urethral catheterization.

The outcome of suprapubic and urethral catheterization in abdominal surgery was compared in a prospective randomized trial. Twenty-eight patients received a suprapubic and 29 a urethral catheter. The groups were similar in terms of age, sex, operation performed and postoperative analgesia. There was no difference in the duration of catheterization (suprapubic: median 5 (range 4-10) days; urethral: median 4 (range 2-11) days). Urinary sepsis occurred in three patients in each group. Urethral catheters caused pain in significantly more patients (urethral 13; suprapubic two; chi 2 = 8.6, 1 d.f. P < 0.01), on more days (suprapubic: 6 of 142 catheter days; urethral: 37 of 126 catheter days; chi 2 = 29.5, 1 d.f. P < 0.001). Two men with urethral catheters and one with a suprapubic catheter failed to void urethrally when required to do so. Suprapubic catheterization is the method of choice for urinary drainage when this is required in abdominal surgery.

Pouch-vaginal fistula after restorative proctocolectomy: aetiology and management.

Pouch-vaginal fistula is a rare complication following restorative proctocolectomy. Seven patients who developed such a fistula are presented. Six pouch-vaginal fistulas occurred at the level of the pouch-anal anastomosis and one 3 cm above the anastomosis, level with the posterior vaginal fornix. The anastomosis had been hand-sewn in four patients (following mucosectomy) and stapled in three. Five fistulas presented within the perioperative period (median 16 (range 10-30) days) and two at 186 and 273 days. Treatment was successful in the patients who presented early, and these remain continent with functioning pouches. If not already present (two patients), an ileostomy was raised. Repair was by endovaginal flap advancement, combined with fistulotomy and sphincter repair in two patients. Treatment was unsuccessful in the two patients who presented late; in both the diagnosis was revised to Crohn's disease, necessitating pouch excision.

Distribution of nitric oxide synthase containing neurons in the rectal myenteric plexus and anal canal. Morphologic evidence that nitric oxide mediates the rectoanal inhibitory reflex.

PURPOSE: Following the demonstration that a novel neurotransmitter, nitric oxide (NO), is released during neurogenic relaxation of the internal anal sphincter in vitro, it has been suggested that NO could mediate the rectoanal inhibitory reflex in vivo. The aim of this study was to establish whether the distribution of NO-producing nerves in the anorectum is consistent with this proposed role. METHODS: NO is synthesized in neurons which contain the enzyme nitric oxide synthase and their presence in the anorectum was determined in tissue obtained from nine abdominoperineal and three anterior resection specimens in patients undergoing surgery for rectal carcinoma. Cryostat sections were stained for nitric oxide synthase immunoreactivity, pan-neuronal/axonal immunoreactivity, and NADPH diaphorase activity. RESULTS: Nitric oxide synthase immunoreactivity is present in a subpopulation of neurons in rectal myenteric ganglia which also contain NADPH diaphorase activity. Use of the latter histochemical technique enabled the structure and distribution of nitric oxide synthase containing neurons to be determined in whole-mount preparations. Individual neurons have Dogiel type 1 morphology and are present throughout the rectal myenteric plexus. In the distal rectum, positively stained axons enter shunt fascicles which descend into the anal canal, where they ramify into and throughout the internal anal sphincter. Within the sphincter, positively stained nerves lie in close proximity to smooth muscle cells. CONCLUSION: These results are consistent with the hypothesis that NO is the neurotransmitter that mediates the rectoanal inhibitory reflex.

Abnormalities of nitric-oxide-producing neurons in Hirschsprung's disease: morphology and implications.

Nitric oxide (NO) is a recently discovered neurotransmitter that is thought to mediate relaxation of gut smooth muscle during peristalsis. To assess its role in the pathophysiology of Hirschsprung's disease, the authors examined the distribution of neurons that produce NO in specimens from seven infants with this condition. Immunohistochemical analysis of cryostat sections for nitric oxide synthase (NOS) immunoreactivity (NOS catalyzes the production of NO) showed that NOS is localized in a substantial subpopulation of enteric neurons in both the myenteric and submucosal plexuses in the ganglionated gut, but it was completely absent in aganglionic bowel. NOS immunoreactivity specifically colocalizes in neurons that also contain NADPH-diaphorase activity. This finding enabled the distribution of NO-producing neurons to be determined using whole-mount histochemistry, a technique that allows the enteric neural network to be examined intact. In normal bowel, NO-producing neurons are arranged in star-shaped myenteric and submucosal ganglia, which are joined to one another by nerve fibers to form a meshwork of variable geometry. Individual neurons exhibit Dogiel type 1 morphology. Axonal processes leave the myenteric plexuses and lie parallel to muscle bundles in both muscle layers of the gut. In the transition zone, ganglia are initially present, but their orientation changes so that both they and the internodal strands that connect them are aligned linearly along the craniocaudal axis of the gut tube. More distal still, ganglia and then all NOS activity disappear completely. These results suggest that in Hirschsprung's disease, the failure of aganglionic bowel to relax during peristalsis might be caused by the absence of NO-producing neurons.

In vitro response of the human anal canal longitudinal muscle layer to cholinergic and adrenergic stimulation: evidence of sphincter specialization.

A study was performed to determine the in vitro response of the longitudinal smooth muscle layer (conjoined longitudinal coat) of the human and canal to cholinergic and adrenergic stimulation, and to compare this with similar features of the internal anal sphincter (IAS) and rectal smooth muscle. Tissue was obtained from abdominoperineal and anterior resection specimens, and strips of muscle mounted for isometric tension recording in superfusion organ baths. Both conjoined longitudinal coat and IAS strips generated and maintained spontaneous myogenic tension (mean(s.e.m.) 0.10(0.01) and 0.48(0.04) g per mg tissue respectively), whereas equivalent rectal smooth muscle did not. Stimulation of muscarinic (cholinergic) receptors caused contraction of strips from the conjoined longitudinal coat and rectal smooth muscle layers in a dose-dependent manner (10(-7)-10(-4) mol/l); however, IAS strips relaxed (10(-6)-10(-4) mol/l). Activation of alpha-adrenergic receptors in conjoined longitudinal coat and IAS strips produced concentration-dependent contraction (10(-7)-10(-4) mol/l). In comparison, rectal smooth muscle relaxed. All muscle layers relaxed in response to beta-adrenoceptor stimulation. These data indicate that in the anal canal both the conjoined longitudinal coat and IAS are specialized sphincteric smooth muscles.

Flexible cystoscopy compared with ultrasound in the detection of recurrent bladder tumours.

A combination of transrectal and transabdominal ultrasound was compared with flexible cystoscopy as a means of detecting recurrent bladder tumours. The study group comprised 50 patients who had previously had rigid cystoscopy. They underwent combination ultrasound in the out-patient department 1 week before flexible cystoscopy. Combination ultrasound identified 25 patients with recurrent tumours and flexible cystoscopy identified 26. Thirty-four patients (68%) preferred ultrasound, 10 (20%) preferred flexible cystoscopy, 3 (6%) preferred general anaesthesia and rigid cystoscopy and 3 (6%) had no preference. The main objection to ultrasound was the use of the transrectal probe.

Trauma centres and the efficient use of financial resources.

The economic aspects of trauma centres were examined using published results and local financial data to discover if such institutions are an efficient use of resources. The cost of trauma centre care depends upon the number of centres built. An 'ideal' system in the UK of eight centres will cost 31.268 pounds per life saved compared with 45.661 pounds for the system proposed by the Royal College of Surgeons of England. Trauma centre care will be expensive but will generate benefits in return. Survivors will be young (mean age 30 years) and most (70-80 per cent) will regain their pre-injury functional/work status. When considered in terms of Quality Adjusted Life Years (QUALYs), trauma centres are a relatively efficient use of resources. An expected cost per QUALY of 942-1376 pounds is inexpensive compared with many health pursuits currently funded within the UK National Health Service.

Which deaths in vascular surgery are avoidable? A review of 150 consecutive deaths occurring on the Oxford regional vascular service.

One hundred and fifty consecutive deaths occurring on the Oxford regional vascular service were reviewed using data collected prospectively by weekly audit to determine which deaths were avoidable. During the period of study there were 2449 admissions to the vascular service and 1796 operations were performed. Of those who died 71 (47%) had aneurysmal disease and 76 (51%) occlusive disease. Most were elderly (89% were over 65 years) and died from their presenting disorder or associated conditions. Thirty-four deaths were considered to have been avoidable and were caused or hastened by errors in management. Twenty-one of these occurred in patients with a ruptured abdominal aortic aneurysm. In eleven cases delayed diagnosis (7) or inter hospital transfer (4) were implicated. Eighteen deaths were associated with surgical and three with anaesthetic errors which would have been undetected but for the weekly audit. Our experience suggests that while early diagnosis of ruptured abdominal aortic aneurysm and rapid transportation to a specialist vascular service would save some lives, technical management errors remain the major cause of avoidable deaths in vascular surgery.

General practice-based population screening for abdominal aortic aneurysms: a pilot study.

All 1195 male patients aged between 65 and 74 years on the Family Practitioner Committee register for the four group practices in Stroud, UK were invited for a health screening check. The examinations included abdominal ultrasonography to measure maximum aortic diameter, measurement of blood pressure and recording of smoking habits. An attendance rate of 76 per cent was achieved (906 patients). Seventy-one patients (7.8 per cent) were found to have aortic diameters greater than 2.5 cm and 14 (1.5 per cent) had aortic diameters greater than 4.0 cm. Aneurysms were more common in smokers and in hypertensive patients. However, restriction of screening to patients with these risk factors would have led to a number of aneurysms remaining undiscovered. We recommend therefore that ultrasound screening for abdominal aortic aneurysms should be offered to all men between the ages of 65 and 74 years.

The feasibility of screening for abdominal aortic aneurysms in a district general hospital.

The feasibility of a screening programme for abdominal aortic aneurysms within a district general hospital population is explored, based on our current accepted knowledge of the natural history of this disease process. It is shown that ultrasound screening of males aged between 65 and 74 years, with elective repair of the aneurysms discovered, could save up to 20 lives per year in this district at a reasonable and justifiable cost. Moreover, such a programme would not place an unacceptable burden on existing radiological and surgical facilities.