Serologic and virologic surveillance of avian influenza in Nigeria, 2006-7.

Since January 2006, H5N1 avian influenza has affected Nigeria's poultry population causing enormous loss of resources. The current circulating virus is a potential candidate for pandemic influenza which may severely affect the human and animal population worldwide especially in the resource-poor countries. In this study, we report on our field and laboratory surveillance efforts in Nigeria. A total of 1,821 tissue samples, 8,638 tracheal swabs, 7,976 cloacal swabs and 7,328 avian sera were analysed over a period of two years, with 312 positive results [corrected] We recovered 299 isolates of highly pathogenic avian influenza virus H5N1 mainly from the diagnostic samples of poultry kept in backyard, small scale and free range farms. This finding emphasised the role played by these farming systems in the dissemination of avian influenza in Nigeria and highlights the need for a continued surveillance in humans since human-animal interaction is a key feature in Africa. Furthermore, there is a need for the strengthening of border controls. Since October 2007, there has been no reported and confirmed outbreak of avian influenza in Nigeria.

Carcinoma of the rectum with a single penile metastasis.

Metastatic disease of colon and rectal carcinoma accounts for a high proportion of cancer related deaths. The common organs involved in metastatic diseases include liver, lung, brain and bone. Although, theoretically possible, metastasis to the other organs are rare. We report the first case of carcinoma of the rectum with a solitary metastasis to the glans penis.

Fecal incontinence: hope for an underdiagnosed condition.

Fecal incontinence is often suffered in silence leading one to become a social recluse. This has led to the belief that the problem does not exist and therefore underdiagnosed. In the last decade, much has been learnt about the understanding of continence and defecation. Quantification of appropriate physiological parameters associated with fecal incontinence have allowed the patients to be assessed using a logical algorithm. More importantly, parallel developments in management techniques of fecal incontinence now allow the categorised patients to be managed logically. The assessment is thus translated into appropriate management plans which range from simple nonoperative medical and dietary manipulation to pelvic floor retraining, sphincter augmentation and finally sphincter reconstruction.

Postoperative intra-abdominal free gas after open colorectal resection.

PURPOSE: An erect chest radiograph for subdiaphragmatic free gas can be a useful adjunct in detecting a defect in gastrointestinal continuity. The usefulness of this test after laparotomy has not been defined, because the period of persistence of free gas is unknown. We set out to determine the length of time for natural absorption of postlaparotomy pneumoperitoneum in a prospective cohort study. METHOD: Plain erect chest radiographs were performed on the second and fourth postoperative day and daily thereafter until the disappearance of subdiaphragmatic free gas after laparotomy. RESULTS: Seventy-five consecutive patients were studied after informed consent. The mean age was 62.1 (standard error of the mean, 1.7) years. On the fifth postoperative day, sixth postoperative day, and seventh postoperative day, 71.6, 80, and 89 percent of patients, respectively, had no visible subdiaphragmatic gas. Five patients had gas persisting beyond the tenth postoperative day. Two of these patients did not have an anastomosis. The use of drainage tubes did not affect significantly the mean time to disappearance of subdiaphragmatic free gas (4.5 vs. 4.9 days; P = 0.45: t-test). The duration of surgery, body mass index, and time to resume bowel function had no significant effect on gas disappearance. Two patients had a clinical leak on the fifth postoperative day. This was manifested as an increase in the collection of subdiaphragmatic gas during the course of a day. CONCLUSION: By the sixth postoperative day 80 percent of patients had no subdiaphragmatic free gas on an erect chest radiograph regardless of the presence of a drainage tube. The erect chest radiograph may therefore be a simple and readily available adjunct in the evaluation of postoperative abdominal pain, especially after the sixth postoperative day when a similar prior examination is done routinely on the fourth postoperative day for comparison.

Surgery may be curative for patients with a localized perforation of rectal carcinoma.

BACKGROUND: Perforation at the time of operation adversely affects the prognosis of rectal cancer. These procedures have been termed 'palliative' or 'non-curative'. The long-term outcome of generalized perforations may be different from that of localized or contained perforations. Although the oncological results may be compromised when the tumour is perforated, results in cases where the perforation is contained may not be as bad as previously thought. An attempt was made to examine the intermediate and long-term results for locally contained perforated rectal cancers. METHODS: Some 848 patients with rectal cancer were operated on between March 1989 and December 1995. Of these, 42 (5 per cent) had a locally contained perforation of the rectum. Median follow-up was 23 (range 12-74) months. RESULTS: The survival of patients with locally contained tumour perforation who underwent resection without macroscopic residual disease (40 per cent at 5 years) was significantly better than that of patients with metastatic disease at the time of surgery (zero at 4 years) (P < 0.01). The survival of patients in whom the tumour was inadvertently perforated during operation was similar to that of patients with locally contained spontaneous tumour perforations. The incidence of local recurrence in these perforated cases was low provided that a wide tumour clearance was achievable at the time of operation. Operative mortality and morbidity rates were not significantly different but the incidence of postoperative wound infection was marginally higher among patients with perforation. CONCLUSION: If clear margins can be obtained at the time of operation the prognosis of locally contained perforated rectal cancers is good and approaches that of a potentially curative resection.

Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence.

PURPOSE: Lateral internal sphincterotomy is the procedure of choice for chronic anal fissure because it relieves symptoms and heals the fissure in nearly all patients. However, there is evidence that fecal incontinence complicates lateral internal sphincterotomy. The aim of this study was to examine the outcome of lateral internal sphincterotomy in terms of fissure healing and incidence of fecal incontinence. METHODS: Between 1984 and 1996, 585 patients underwent lateral internal sphincterotomy and were surveyed by questionnaire. Eighty-three percent (487/585) responded. The mean follow-up was 72 (range, 6-145) months. RESULTS: Fissures had healed by a median of three weeks after surgery in 96 percent of patients. Recurrent fissures occurred in 8 percent. Two thirds of the recurrent fissures healed on conservative management alone. Ninety-eight percent of patients were satisfied with the outcome of surgery, but some degree of fecal incontinence occurred in fully 45 percent of patients at some time in the postoperative period. Incontinence occurred in 53.4 percent of women and 33.3 percent of men (P < 0.05). Incontinence to flatus, mild soiling, and gross incontinence occurred in 31, 39, and 23 percent of patients, respectively. However, by the time of survey (a mean of >5 years after lateral internal sphincterotomy) 6 percent reported incontinence to flatus, 8 percent had minor fecal soiling, and 1 percent experienced loss of solid stool. Importantly, only 3 percent of patients stated that incontinence had ever affected their quality of life. CONCLUSION: Although lateral internal sphincterotomy heals and relieves symptoms of chronic anal fissure in nearly all patients (96 percent), incontinence occurs frequently. Most episodes of incontinence are indeed minor and transient, but in a small subgroup, incontinence seems to be permanent.

Palliative surgery for locally recurrent colorectal cancer.

BACKGROUND: Recurrent colorectal cancer carries a poor prognosis. Radical re-resection is the only chance for long-term survival but suitable candidates are few. AIM: To determine the patterns of recurrence after potentially curative colorectal surgery and analyse the results of palliative surgery for patients with local recurrence. METHODS AND RESULTS: Between May 1989 and May 1995, 1,287 case records of patients with colorectal carcinoma were entered into a customized computer database. Of these, 1,103 underwent potentially curative resections (Duke's stage A, B and C). At a median of 40 months (range 2-72) following surgery, 173 patients had recurrent disease detected (98 males; 75 females) at a median of 14 months (range 3-30) after the index surgery. Twelve percent had recurrent distal and locoregional disease while 6.8% had locoregional recurrent disease alone. Thirty-seven patients with locally recurrent disease underwent surgery. Of these, only 7 patients with local recurrences were suitable candidates for resections. The remaining 30 underwent palliative surgery for emergent indications of obstruction (28) and bleeding (2). The symptoms were palliated surgically by an entero-enterostomy (13), defunctioning stoma (12), lysis of adhesions (1), exploratory celiotomy (2) and formalin application (2). Seventeen patients are alive at follow-up. Twenty patients died at a median of 4 months after surgery (range 1-15). All patients had palliation of their symptoms. CONCLUSION: Low incidences of local recurrences can be achieved after potentially curative resections for colorectal carcinoma. When recurrences occur, a small number can be salvaged with a re-resection which is the procedure of choice. Palliative procedures for emergent indications of obstruction and bleeding can give good palliation despite the absence of the possibility of cure.

Management of iatrogenic rectourethral fistula.

PURPOSE: Rectourethral fistulas are uncommon, usually iatrogenic injuries that are challenging to treat. Our aim was to determine a logical approach to surgical treatment of this often debilitating problem. METHODS: Records of all patients who were diagnosed with rectourethral fistula between January 1981 and December 1995 were reviewed and 16 males were identified. All but three patients had had intervention for their prostatic malignancy performed elsewhere. All patients were interviewed by telephone to establish follow-up. The mean age of the sixteen patients was 68 years. The mean follow-up was 80 months. Adenocarcinoma of the prostate in 15 patients and recurrent transitional cell epithelioma of the bladder in one patient were the underlying malignant diseases. Seven patients had a radical retropubic prostatectomy, two had radical retropubic prostatectomy after radiation, two had brachytherapy, and three were treated by a combination of radiation and brachytherapy. One patient formed a fistula after cystectomy and dilation of a stricture. This heterogenous group of patients received multiple therapies including initial colostomy (7 patients), transanal repair (2 patients), parasacral repair (2 patients), transperineal repair (2 patients), coloanal anastomosis (3 patients), and muscle transposition (3 patients). Four of our patients required a permanent stoma. CONCLUSION: In patients with iatrogenic rectourethral fistula that occurred after radical retropubic prostatectomy or radiation, fecal and urinary diversion and muscle transposition followed by re-establishment of both urinary and intestinal continuity may be the treatment modality of choice.

Minimizing recurrence after sigmoid volvulus.

BACKGROUND: This study was a retrospective review of a series of patients with sigmoid volvulus to identify risk factors for recurrence and recommend appropriate treatment. METHODS: Thirty-five patients with sigmoid volvulus were treated over 8 years. RESULTS: Six patients had emergency surgery for peritonitis. Twenty-eight of the other 29 patients had successful endoscopic decompression; 15 of these patients had elective surgery during the same admission. Twelve of the 14 patients who refused operation after endoscopic decompression developed recurrent volvulus, a median of 2.8 months later. Eight subsequently agreed to surgery and underwent elective operation following repeat decompression. Of 29 patients who had surgery, 27 had sigmoid colectomy (two were initial Hartmann procedures) and two had subtotal colectomy. Six patients who had sigmoid colectomy developed recurrent volvulus. Concomitant megacolon and megarectum at the time of initial surgery were significant predictors of recurrence. CONCLUSION: Subtotal colectomy, carried out as the primary procedure if there is concomitant megacolon or megarectum, might reduce the risk of recurrent sigmoid volvulus.

Transpelvic rectus abdominis flap for perineal reconstruction following abdominal perineal resection with en bloc partial cystectomy and prostatectomy for locally advanced rectal cancer.

We report a case of locally advanced carcinoma of the rectum invading the bladder and prostate in a young man treated initially with neoadjuvant chemoradiotherapy. This was followed by an en bloc resection of the tumour, partial cystectomy and prostatectomy and an abdominal perineal resection. The urinary bladder was reconstructed and a new bladder neck reimplanted into the proximal urethra where the sphincter had been preserved. There was extensive radiation changes to the perineal skin where a wide excision had been performed. The pelvic defect was reconstructed with a pedicled transpelvic rectus abdominis myocutaneous flap. The patient recovered uneventfully and remains well with no clinical evidence of recurrence 18 months post-operatively. In very selected cases there is a definite role for neoadjuvant therapy and enbloc resection of the tumour followed by reconstruction of the perineum.

Young age is not a poor prognostic marker in colorectal cancer.

BACKGROUND: There is still considerable controversy and debate regarding the features and prognosis of colorectal cancer in young patients. METHODS: One hundred and ten patients (5.1 per cent) under the age of 40 years with colorectal cancer (group Y; male: female ratio 48:62) were compared with 2064 patients with colorectal cancer aged 40 years or more (group O; 917 women, 1147 men). Mode of presentation, stage at diagnosis, tumour characteristics and survival were analysed. RESULTS: Predisposing malignant conditions and family history of colorectal cancer were present in 20.9 per cent of patients in group Y versus 2.2 per cent in group O (P < 0.001). Common chief complaints included change in bowel habits, bleeding from the rectum and a significantly higher incidence of abdominal pain in group Y. There was no difference in stage at presentation between the two groups (the proportion of Dukes stage A, B, C and 'D' lesions in group Y was 8.2, 24.5, 37.3 and 30.0 per cent respectively versus 10.5, 27.9, 33.4 and 28.1 per cent in group O). Tumour site and characteristics were similar in both groups. The incidence of mucinous/signet ring cell and poor grade tumours was 6.9 and 11.8 per cent respectively in group Y and 4.5 and 10.5 per cent in group O. With a mean follow-up of 31.8 months, the overall 5-year survival rate was 54.8 per cent in group Y and 54.1 per cent in group O. Comparing stage for stage, survival was not significantly different in the two groups. However, the adjusted hazard ratios of the age groups Y, M (40-59 years), S (60-79 years), and E (80 years and above) were 1.3, 1 (baseline for calculations), 1.4 and 2.4 respectively, suggesting an adverse outcome for patients in group Y compared with patients aged 40-59 years. CONCLUSION: This study revealed no difference in tumour characteristics and survival in patients with colorectal cancer aged less than 40 years compared with those aged above 40 years. However, a higher hazard ratio in the youngest group may connote a worse prognosis than that for those aged 40-59 years. A significant family history of colorectal cancer and predisposing conditions in the young warrants aggressive screening, surveillance and treatment of the underlying conditions. The detection of colorectal cancer in young patients should be no different from that in the old but demands a high index of suspicion.

The current understanding of continence and defecation.

Problems of continence and defecation are encountered in all facets of medical practice. Yet, the anorectum is cloaked by misunderstanding. Recent research has shed new light on this subject and newer concepts based on systematic investigations have paved the way to a rational approach. Motor function of the anorectum can now be delineated by manometry, electromyography and nerve stimulation. More complex functions like the coordination for continence and defecation are measured using other studies including defecating proctography, scintigraphic balloon topography, scintigraphic evacuation and colonic transit. The amalgamation of data from these studies have led to a logical sequence for the maintenance of normal continence and defecation that is developed in this manuscript based on our current understanding of anorectal motility and physiology. This allows patients who are resistant to straightforward diagnosis to be selected for specialised tests resulting in categorisation and a rational management strategy for their problems.

Large aggressive angiomyxoma of the perineum and pelvis: an alternative approach. Report of a case.

Aggressive angiomyxomas are rare soft tissue tumors found mainly in the female reproductive mesenchyme and pelvis. They are low-grade sarcomas that have a propensity to recur locally. These tumors are encapsulated and have the same consistency as normal connective tissue, thus making wide excision difficult. We report a case of a large aggressive angiomyxoma in the perirectal tissues treated with preoperative angiographic embolization, causing ischemia of the tumor and, thus, improved visualization of the lesion. In addition, preoperative external beam irradiation and intraoperative electron beam radiotherapy were used to decrease the chances of local recurrence.

Management of colonic lipomas.

BACKGROUND: Little is known of colonic lipomas, especially in an Asian population, and their management is controversial. METHODS: A computerized colonoscopy database was analysed and patients with colonic lipomas were reviewed. RESULTS: There were 16 colonic lipomas (incidence of 0.15%) in a series of 10658 consecutive colonoscopies. There were seven men and nine women, with a mean age of 61.8 years (range: 28-80 years). The size of the lipomas ranged from 1.5 to 6 cm; all those larger than 3.5 cm were symptomatic (P = 0.05). The most common symptom was mild bleeding per rectum. Right-sided lipomas were palpable while left-sided lipomas presented with obstructive symptoms. Colonoscopic removal by hot biopsy or snare polypectomy was possible where the lipomas were 2.5 cm and pedunculated. Surgery was performed in six patients (four open, two laparoscopic) for symptoms and to exclude malignancy. There was no morbidity or mortality. CONCLUSIONS: Small or pedunculated lipomas may be safely removed colonoscopically and the diagnosis confirmed histologically. Larger lipomas require surgical resection for relief of symptoms or to exclude malignancy.

The current status of intraoperative radiotherapy in colorectal surgery.

Colorectal cancer is the second most common malignancy in Singapore and its incidence is increasing. Results of surgery have been augmented in selected cases by the addition of radiotherapy and chemotherapy. This standard approach only offers palliation in locally advanced and locally recurrent cancers. Newer modalities and combinations are currently being investigated to improve the results in this particular group of patients. One such modality is the use of intraoperative radiotherapy (IORT). This paper discusses the rationale for using IORT, the patient selection, method of delivery and treatment, tolerance and results in centers which have been using IORT as part of a multi-modality therapy for colorectal cancer.

Ileal pouch-anal canal anastomosis for familial adenomatous polyposis: early and late results.

OBJECTIVE: The objective was to review the early and late results of ileal pouch-anal anastomosis (IPAA) done for patients with familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: Patients with FAP will have colorectal adenomas develop and die of colorectal cancer if left untreated. Ileal pouch-anal anastomosis removes all disease-bearing mucosa while preserving transanal passage of stools. METHODS: Between 1981 and 1994, 187 patients with FAP, 11 to 59 years of age with a mean follow-up of 60 months (range, 5-170 months) had proctocolectomy and IPAA at Mayo Medical Center in Rochester, Minnesota. All patients had a proximal anal canal mucosal excision and a hand-sewn anastomosis of the pouch to the anal canal at the dentate line. A temporary ileostomy was used in 85% of the patients. RESULTS: No early postoperative deaths occurred, although two patients died later of metastatic colorectal carcinoma present at their initial operation. More important, no patient had a new cancer develop after IPAA. The overall morbidity after operation was 24%, with small bowel obstruction being the most common complication (13%). Patients had four bowel movements/24 hours and good fecal control, which continued during follow-up. CONCLUSIONS: The IPAA eradicates the risk of colorectal cancer in patients with FAP. It can be performed with low mortality, acceptable morbidity, and good functional results over the long term.

Lymphoma of the pouch after ileal pouch-anal anastomosis: report of a case.

The most common cause of pouch dysfunction after ileal pouch-anal anastomosis is pouchitis. Although low-grade dysplasia in the mucosa of the pouch has been recently described in the presence of pouchitis, there has been no report of carcinoma arising in the pouch itself. We describe a patient who developed a large-cell lymphoma of the ileal pouch after ileal pouch-anal anastomosis.

Does the presence of a pre-ileostomy closure asymptomatic pouch-anastomotic sinus tract affect the success of ileal pouch-anal anastomosis?

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. This two-stage procedure with a temporary diverting ileostomy avoids the catastrophic consequences of anastomotic leakage. We set out to determine the incidence and effect of asymptomatic pouch sinuses detected prior to ileostomy closure on the outcome of IPAA. A total 1600 IPAAs performed at the Mayo Clinic were reviewed. Forty-one (2.6%) asymptomatic sinuses were treated expectantly. There were 22 males and 19 females who had a median age of 32 years (range 14 to 58 years). The median time to ileostomy closure was 5.9 months (range 4 to 11 months). Five patients required further surgery following closure of ileostomy. The pouch function in these five patients was similar to that in the remainder of the group. Patients with a persistent sinus at the time of ileostomy closure had the same function as the main cohort. This group had a median of five (range 2 to 12) stools during the day and two (range 0 to 4) at night. The total number of stools per 24 hours was seven (range 2 to 14). Frequent incontinence occurred in 9.7% and 7.3% during the day and at night, respectively. Only 2.4% (1/41) were disappointed with the results of the operation and 80.4% (33/41) found their quality of life improved. Functional outcomes were comparable to those achieved with uncomplicated IPAA. Radiologically detected asymptomatic sinuses can be treated expectantly with a low rate of pouch loss and subsequent surgery. This is not considered a serious setback inasmuch as long-term function and quality of life are comparable to that achieved with IPAA without sinus tracts.

Long-term results of surgery for chronic constipation.

BACKGROUND: Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation. AIM: Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention. MATERIALS AND RESULTS: Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction. CONCLUSION: Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.

An endoscopic diagnosis of appendicular intussusception in chronic appendicitis.

We report a rare case of chronic appendicitis causing recurrent intussusception in a 33-year-old man who had recurrent episodes of right iliac fossa pain diagnosed clinically and confirmed by colonoscopy. This is the first known case with the rare combination diagnosed endoscopically.