Insert devices for faecal incontinence.

BACKGROUND: Faecal incontinence (FI) affects 1-19% of the general population and carries significant physical and psychological morbidity. Treatment strategies vary greatly with respect to morbidity and efficacy and relatively little is known regarding the role of mechanical devices such as anal and vaginal inserts. This is an up-to-date systematic review of the use of these devices in the management of patients with FI. METHODS: A systematic electronic search was performed of the Medline, Pubmed and Embase databases using the key words and/or MeSH 'anal plug', 'anal insert', 'vaginal insert' and 'faecal incontinence'. Only articles that reported clinical outcomes for these devices for FI in the English language were included. Review articles were excluded to avoid duplication of data. RESULTS: Thirteen articles fulfilled the eligibility criteria. Two articles reported outcomes for the Eclipse vaginal insert and 11 articles reported on three types of anal inserts; the Coloplast 'Tulip' design (6), the Procon/ProTect device (2) and the Renew insert (3). When tolerated, both anal and vaginal inserts significantly improved continence, bowel function and quality of life where reported. Adverse effects included discomfort, leakage and slippage. Long-term compliance and benefit are yet to be determined. CONCLUSIONS: Vaginal and anal inserts may be a useful treatment for FI. Better quality of evidence is needed to define its effectiveness.

Negative pressure therapy for stoma closure sites-a nonrandomised case control study.

AIM: The PICO (Smith & Nephew, UK) dressing is a single use negative pressure wound therapy (NPWT) system that is designed to be used for up to 7 days for closed wounds. We aimed to assess its use for stoma closure wounds. METHOD: We conducted a retrospective analysis of stoma reversal wounds from April 2018 to June 2019. The wound was partially closed with an absorbable subcutaneous suture in a purse-string fashion. A 15 cm × 15 cm PICO dressing was applied directly over this wound. A control group who had received partial purse string closure with packing over the same time period was identified. Patients were contacted and information collected using a questionnaire. The primary outcome measure was the number of visits for dressing changes in the community. Further information was collected about length of stay, time to resolution of pain and return to work. RESULTS: On average, the patients with PICO dressings attended the community nurses 1.9 times. The patients in the PICO group stated it took 1-2 weeks to return to full work/daily activities. The control group averaged attending the community nurse 11.9 times, and 33% had not returned to work/daily activities in 1-2 weeks. CONCLUSION: Those who had a PICO dressing required fewer visits to the community nurse and the majority were able to return to work or resume usual activities within 1 to 2 weeks. This pilot study suggests that negative pressure dressings may be a useful aid for stoma closure site wounds.

A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage.

OBJECTIVE: Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment. PATIENTS AND METHODS: GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour. RESULTS: There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty-two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005). CONCLUSION: Fifty-three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.

Prosthetic graft seeding: breathing new life into old grafts.

A major constraint in vascular surgery is the failure of the currently available prosthetic grafts to match the patency of autogenous vein below the inguinal ligament. Endothelial seeding aims to produce an endothelial lining which is otherwise absent from prosthetics. This could improve patency by preventing thrombosis and the release of mitogens by activated platelets implicated in the development of neointimal hyperplasia. Experimental evidence supports the potential of the technique but clinical trials have been less conclusive. A number of problems need to be solved if this application of cell biology is to become a part of vascular surgical practice.

The effect of platelet inhibitory therapy on graft thromboresistance.

Greyhounds (n = 38) were randomized to aspirin and dipyridamole (ASA + DPM), the thromboxane synthetase inhibitor (TSI) CGS12970 (CIBA-GEIGY) or placebo twice daily for 48 hours prior to bilateral implantation of femoral artery Dacron grafts. In-vivo 111In-platelet deposition on grafts was measured at 5 days and 2 months. Grafts were removed at 2 months when ex-vivo graft and arterial release of 6-ketoprostaglandin F1a (6-keto PGF1a) was measured by radioimmunoassay. Graft 6-keto-PGF1a was significantly increased by CGS12970 but ASA + DPM had no significant effect. ASA + DPM significantly reduced arterial 6-keto-PGF1a although this was marginally increased by CGS12970. Neither active treatment reduced in-vivo 111In-platelet deposition. Preservation of vascular or graft prostacyclin by thromboxane synthetase inhibitors may represent an alternative strategy in preventing prosthetic graft thrombosis.

Mesothelial seeding of knitted Dacron.

Bilateral superficial femoral artery replacement using knitted Dacron was performed in 38 dogs. One side was seeded with omental mesothelium and the other acted as an unseeded control. 111In-labelled platelet accumulation on grafts was measured at 5 days and 2 months and the thrombogenicity index of seeded and unseeded grafts calculated. Patency was monitored for 2 months, at which time grafts were removed and luminal thrombus, ultrastructural cell cover and prostacyclin release were measured. Cell seeding did not influence the mean(s.e.m.) thrombogenicity index of 0.95(0.25) and 0.88(0.24) at 5 days in control and seeded grafts respectively; nor was there any difference between the groups at 2 months. Occlusion occurred in six control and four seeded grafts. Seeding did not significantly improve the percentage thrombus-free area or luminal cell cover. Neither did it enhance mean(s.e.m.) luminal 6-keto-prostaglandin F1 alpha release of 2.58(0.80) pg cm-2 in controls and 2.63(0.78) pg cm-2 in seeded grafts. Further studies demonstrated that only a mean(s.e.m.) of 4.4(1.9) per cent of the seeded inoculum was present on grafts 48 h after implantation, providing too few cells to achieve confluent cover. Mesothelial cell seeding might be useful in promoting a healed graft surface but critical levels of seeding density must be achieved before the technique can be properly evaluated.

The influence of collagen and albumen presealants on knitted Dacron grafts.

Dacron arterial grafts may be sealed with collagen or albumen to avoid preclotting. The influence on graft thrombogenicity and maturation was studied in 36 patients undergoing elective arterial bypass surgery for aortoiliac disease randomised to (i) collagen impregnated (Meadox Hemashield), (ii) albumen coated (USCI) or (iii) standard knitted Dacron (Meadox Microvel, UCSI Vasculour II) preclotted with the patient's own blood. Five days and 2 months postoperatively, autologous 111indium-labelled platelet deposition was measured as the daily increase in the ratio of graft to blood radioactivity and expressed as the Thrombogenicity Index (TI) (units, 10(-3). Duplex Doppler examination was used to detect thrombus, neointima or perigraft fluid. TI (median and interquartile range) was similar in the grafts at 5 days at 2.12 (-0.026-3.67) for preclotted Dacron, 2.72 (1.69-7.15) for collagen impregnated and 2.7 (2.13-8.56) for albumen coated Dacron, and was not significantly different at 2 months at 2.66 (2.07-5.18) (n = 9), 4.22 (1.3-7.02) (n = 8) and 2.89 (1.03-16.5) (n = 7), respectively. Duplex Doppler demonstrated perigraft fluid at the proximal anastomosis of an occluded albumen coated graft but no further abnormalities were detected. On these data sealing of knitted Dacron with collagen or albumen does not influence early graft thrombogenicity or maturation.

The effect of platelet inhibitory therapy on prosthetic graft maturation.

Thirty-eight dogs were randomized to the thromboxane synthetase inhibitor CGS12790 (3 mg/kg), aspirin 150 mg and dipyridamole 50 mg (ASA + DPM) or placebo (PLA), all twice daily. Two days later, animals underwent bilateral superficial femoral artery replacement with knitted Dacron. Grafts were removed at two months and subjected to macroscopic and histological examination. Thirty dogs survived to two months. Percentage thrombus free area (TFA) was increased from 15.1 +/- 2.2 with PLA to 46.6 +/- 5.2 with CGS12970 (P < 0.001) and to 32.9 +/- 5.0 with ASA + DPM (P < 0.01). At the anastomoses, only CGS12970 significantly reduced neointimal thickness, promoted pannus ingrowth and improved endothelialization. Percentage luminal occlusion at the midgraft was reduced from 48.2 +/- 5.9 with PLA to 33.9 +/- 2.7 with CGS12970 (P < 0.05). These results provide further evidence that platelet inhibitory therapy reduces thrombosis but also that the platelet is involved in anastomotic maturation. Therapy directed against thromboxane synthesis has potential that may be useful in clinical practice.

An immunohistochemical study of mesothelial cell seeding for knitted Dacron.

Six greyhounds underwent bilateral femoral artery replacement with knitted Dacron, one side seeded with omental digest at graft preclotting, the other acting as an unseeded control. Grafts were removed at 24 hours and two months. Tissue was examined using a monoclonal antibody (MNF116) directed against a broad range of human cytokeratins to differentiate mesothelial cells (MC) from microvascular endothelial cells (MEC), which stained only with a polyclonal antibody directed against von Willebrand Factor (anti-vWF). Cells released from omentum by collagenase stained with MNF116 and reacted poorly with anti-vWF. Identical cells were observed to be within the interstices of seeded but not control knitted Dacron. Few remained in seeded grafts (n = 2) removed at 24 hours and none at two months (n = 4).

Ruptured abdominal aortic aneurysm presenting with acute urinary retention.

Ruptured abdominal aortic aneurysm classically presents with abdominal pain radiating to the back, a pulsatile abdominal mass and circulatory collapse. However, other symptoms may be the only presenting complaint. We report the case of a patient who presented with a history of acute retention of urine relieved by catheterisation, but who then developed clinical features more typical of abdominal aortic aneurysm rupture.