Male faecal incontinence presents as two separate entities with implications for management.

AIM: In contrast to females, male faecal incontinence has received little attention. We investigate its pattern and management at a large UK teaching hospital. METHODS: Men presenting with faecal incontinence between January 2006 and December 2008 were identified from a gastrointestinal physiology database and classified into faecal leakage or faecal incontinence on the basis of symptomatology. Demographics, Cleveland Clinic incontinence score (CCIS), aetiological factors, investigations and treatments were collected by case note review and compared to clinical outcomes. RESULTS: Forty-three symptomatic patients were identified with faecal incontinence, in which 33 were classified as having faecal leakage (FL) and ten as faecal incontinence (FI). The mean CCIS was 10.7 (range, 4-14) and 14.2 (8-20) for FL and FI, respectively. The FL group had normal anal sphincter pressures, whilst the FI group had significantly lower mean resting pressure, 45 mmHg (8-90 mmHg), and mean squeeze pressure, 62.1 mmHg (18-110 mmHg). Thirteen out of 33 patients in the FL group and seven out of ten in the FI group had undergone previous anorectal surgery and had demonstrable sphincter defects whilst in the remainder, no definite aetiological factor could be identified. All patients in the FL group improved with lifestyle changes (28/33) or biofeedback (5/33). Six patients in the FI group required surgical intervention (3/6, collagen injection; 1/6, graciloplasty; 1/6, sacral nerve stimulation; 1/6, rectopexy). CONCLUSIONS: Patients presenting with FL characteristically have normal anorectal physiology and respond to non-operative measures, as compared to patients with FI who tend to have weakened anal sphincters, previous history of anorectal surgery, and more often require surgical intervention.

Metastatic Gas gangrene and Colonic Perforation: a case report.

Clostridium septicum myonecrosis is associated with diabetes, colorectal and haematological malignancies. We present a case of metastatic myonecrosis in a diabetic patient with a perforated caecal tumour. The literature since 1989 is reviewed and 28 cases of Clostridium septicum myonecrosis are discussed.

Evaluation of a protocol-based management of rectal cancer.

INTRODUCTION: The management of rectal cancer is multidisciplinary. We have devised and implemented a standardized protocol. This study was designed to evaluate the protocol and identify areas for improvement. METHODS: All patients with a diagnosis of rectal cancer were staged preoperatively. Magnetic resonance imaging and computed tomography were used to predict whether surgical resection would be complete (RO) or involved (R1/2). Data were collected on preoperative adjuvant therapy, surgical procedure, and subsequent pathologic stage, including circumferential resection margin status. RESULTS: Between January 2000 and October 2002, 163 patients were studied (107 male; median age, 70 (range, 60-77) years). One hundred and fifty seven patients underwent surgical excision for rectal cancer of whom 155 were discussed in the multidisciplinary meeting. One hundred seventeen patients (75 percent) had pelvic magnetic resonance scan and staging computed tomography of chest and abdomen, whereas 38 had computed tomography only. Seventy-seven tumors were predicted as R0 and 78 as likely R1/2. In the predicted RO group, 50 had surgery alone, 25 had short-course radiotherapy, and 2 had chemoradiotherapy. Twelve patients (15.5 percent) had involved circumferential resection margin on the histologic specimen. In the predicted R1/2 group (n = 78), 40 patients received chemoradiotherapy, 11 had short-course radiotherapy, and 27 had surgery alone. Thirty patients (38.4 percent) had involved circumferential resection margin. Circumferential margin involvement was seen in 11 of 40 patients (27.5 percent) who received chemoradiotherapy, 6 of 11 patients (54.5 percent) who received short-course preoperative radiotherapy, and 13 of 27 patients (48.1 percent) who had surgery alone. CONCLUSIONS: Protocol-driven management of rectal cancer within the context of a multidisciplinary team has been demonstrated to work. Regular audit allows for modification and improvement of the protocol as newer management strategies evolve.