Rice-based integrated farming system improves the soil quality, bacterial community structure and system productivity under sub-humid tropical condition.

Rice-based integrated farming system improves the productivity and profitability by recycling resources efficiently. In the sub-humid tropics, rice production without sufficient nutrient replenishment often leads to soil health and fertility degradation. There has been very limited research on soil health and fertility after adopting a multi-enterprising rice-based integrated farming system (IFS), notably in the rice-fish-livestock and agroforestry system, when compared to a conventional farming system (CS). Therefore, the present study analyzed the dynamics of soil properties, soil bacterial community structure and their possible interaction mechanisms, as well as their effect on regulating soil quality and production in IFS, IFSw (water stagnant area of IFS) and CS. The results indicated that soil nutrient dynamics, bacterial diversity indices (Shannon index, Simpson index, Chao 1, ACE and Fisher index) and system productivity were higher in IFSw and IFS compared to CS. Moreover, relative operational taxonomic units of dominant bacterial genera (Chloroflexi, Acidobacteria, Verrucomicrobia, Planctomycetes, Cyanobacteria, Crenarchaeota and Gemmatimonadetes) were also higher in IFSw and IFS compared to CS. Mean soil quality index (SQI) was highest in IFSw (0.780 ± 0.201) followed by IFS (0.770 ± 0.080) and CS (0.595 ± 0.244). Moreover, rice equivalent yields (REY) and rice yields were well correlated with the higher levels of soil biological indices (SQIBiol) in IFS. Overall, our results revealed that rice-based IFS improved the soil health and fertility and ensuing crop productivity through positive interaction with soil bacterial communities and nutrient stoichiometry leading to agroecosystem sustainability.

Impact of long-term resource conservation techniques on biogeochemical characteristics and biological soil quality indicators in a rice green-gram farming system.

Nutrient management in resource conservation practices influence the structural and functional microbial diversities and thereby affect biological processes and biochemical properties in soil. We studied the long-term effects of resource conservation technologies on functional microbial diversity and their interactions with soil biochemical properties and enzymatic activities in tropical rice-green gram cropping system. The experiment includes seven treatments viz., conventional practice (CC), brown manuring (BM), green manuring (GM), wet direct drum sowing, zero tillage, green manuring-customized leaf colour chart based-N application (GM-CLCC-N) and biochar (BC) application. The result of the present study revealed that microbial biomass nitrogen (N), carbon (C) and phosphorus (P) in GM practice were increased by 23.3, 37.7 and 35.1%, respectively than CC. GM, BM and GM-CLCC-N treatments provide higher yields than conventional practice. The average well color development value, Shannon index and McIntosh index were significantly higher by 26.6%, 86.9% and 29.2% in GM as compared to control treatment. So, from this study we can conclude that resource conservation practices like GM, GM-CLCC N and BM in combination with chemical fertilizers provide easily decomposable carbon source to support the microbial growth. Moreover, dominance of microbial activity in biomass amended treatments (GM, GM-CLCC N and BM) indicated that these treatments could supply good amount of labile C sources on real time basis for microbial growth that may protect the stable C fraction in soil, hence could support higher yield and soil organic carbon build-up in long run under rice-green gram soil.

Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn's disease with a higher ileostomy and complication rate.

BACKGROUND: Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease. METHODS: A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes. RESULTS: One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease. CONCLUSIONS: Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

Emergency general surgeons, subspeciality surgeons and the future management of emergency surgery: results of a national survey.

AIM: This study aimed to survey consultants' experience of working as or with emergency general surgery (EGS) surgeons and to investigate the role they fulfil in the management of general and subspeciality emergencies. METHOD: An electronic survey, designed to capture both quantitative and qualitative data, was piloted and then circulated to members of the Association of Coloproctology of Great Britain and Ireland. RESULTS: Two hundred and forty-two responses were received from 848 recipients (a 29% response rate) covering 104 of 135 (77%) acute NHS Trusts in England. EGS surgeons were in post in 43/141 (30%) hospitals overall and 12/24 (50%) of hospitals in London. Most respondents working in units with EGS surgeons found them to be advantageous (46/63, 73%). Consultants working with EGS surgeons were significantly more likely to support their use (49/63, 78%) than those without them (83/178, 47%) (χ2  = 16.9, P < 0.001). EGS surgeons were considered to improve the delivery of EGS (78%), create time for subspecialists (70%) and provide service (73%). However, there were concerns about the quality of surgery (43%), an insufficient standard of specialist care (54%) and compromise in the training of juniors (25%). Respondents commented on a lack of job structure with a high attrition rate (21%), the insufficient quality of applicants (18%) and that subspecialization and split on-call was preferable (17%). CONCLUSION: Respondents were supportive of the ability of EGS surgeons to relieve pressure on subspecialists; however, there were significant concerns about the sustainability and quality of the EGS surgeon role. Emergency colorectal resections should have the input of a surgeon who performs elective colorectal resections.

Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI).

BACKGROUND: The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics. METHODS: This was a 22-year (1986-2007) retrospective cohort analysis of data collected prospectively from patients who attended colorectal surgical outpatient clinics in Portsmouth. The data set was split randomly into two groups of patients to generate and validate a predictive model. Multivariable logistic regression was used to create and validate a system to predict outcome. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow test were used to evaluate the model's predictive capability. The likelihood of bowel cancer was expressed as the odds ratio (OR). RESULTS: Data from 29 005 patients were analysed. Discrimination of the model for bowel cancer was high in the development (C-statistic 0·87, 95 per cent c.i. 0·85 to 0·88) and validation (C-statistic 0·86, 0·84 to 0·87) groups. The most important co-variables in the final model were: age (OR 3·17-27·10), rectal (OR 31·48) or abdominal (OR 1·83-8·45) mass, iron deficiency anaemia (IDA) (OR 4·42-8·38), rectal bleeding and change in bowel habit in combination (OR 5·37), change in bowel habit without rectal bleeding, with or without abdominal pain (OR 2·12-2·52), and rectal bleeding with no perianal symptoms and without change in bowel habit (OR 2·91). Some 91·5 per cent of bowel cancers presented with these characteristics, 40·4 per cent with a mass and/or IDA. In patients with at least one of these characteristics the overall risk of having cancer was 10·0 (range 6·5-50·4) per cent, compared with 1·1 (0·3-2·3) per cent in patients without them. CONCLUSION: A clinical assessment that systematically identifies or excludes four symptom-age combinations, a mass and IDA (SAMI) stratifies patients as having a low and higher risk of having bowel cancer. This could improve patient selection for referral and investigation.

Resource variation in colorectal surgery: a national centre level analysis.

AIM: Delivery of quality colorectal surgery requires adequate resources. We set out to assess the relationship between resources and outcomes in English colorectal units. METHOD: Data were extracted from the Association of Coloproctology of Great Britain and Ireland resource questionnaire to profile resources. This was correlated with Hospital Episode Statistics outcome data including 90-day mortality and readmissions. Patient satisfaction measures were extracted from the Cancer Experience Patient Survey and compared at unit level. Centres were divided by workload into low, middle and top tertile. RESULTS: Completed questionnaires were received from 75 centres in England. Service resources were similar between low and top tertiles in access to Confidential Enquiry into Patient Outcome and Death (CEPOD) theatre, level two or three beds per 250 000 population or the likelihood of having a dedicated colorectal ward. There was no difference in staffing levels per 250 000 unit of population. Each 10% increase in the proportion of cases attempted laparoscopically was associated with reduced 90-day unplanned readmission (relative risk 0.94, 95% CI 0.91-0.97, P < 0.001). The presence of a dedicated colorectal ward (relative risk 0.85, 95% CI 0.73-0.99, P = 0.040) was also associated with a significant reduction in unplanned readmissions. There was no association between staffing or service factors and patient satisfaction. CONCLUSION: Resource levels do not vary based on unit of population. There is benefit associated with increased use of laparoscopy and a dedicated surgical ward. Alternative measures to assess the relationship between resources and outcome, such as failure to rescue, should be explored in UK practice.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery.

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Life after PROSPER. What do people do for external rectal prolapse?

AIM: A questionnaire completed by members of the ACPGBI in 1997 was a precursor to the PROSPER trial. It showed a significant variation in favoured practice for the surgical treatment of external rectal prolapse. We repeated the same questionnaire to assess how practice has changed since the completion of the trial and its publication. METHOD: An online survey was circulated to all members of the ACPGBI with identical questions to those used in the original in 1997. RESULTS: Similar numbers of recipients responded (122/791 [15.4%] in 2014;153/600 [25.5%] in 1997). The median number of operations per surgeon per year was unchanged (6 [0-30] vs 6 [0-25]). The percentage of surgeons who favoured an abdominal approach in fit patients in 1997 rose significantly from 63.5% to 81.7% in 2014 (P < 0.01). Delorme's remains the most popular perineal procedure (78.5% vs 93.3%), but the Altemeier procedure increased from 14.9% to 39.3%. Ventral rectopexy was the preferred abdominal approach in 2014 (48.6% vs 5.9% [P < 0.01]), with 96.3% of these being performed laparoscopically. The number of surgeons carrying out posterior rectopexy decreased from 92.6% to 45.9% (P < 0.01). Only 9.9% of surgeons still undertook resection rectopexy compared with 39.7% in 1997 (P < 0.01). The numbers of surgeons favouring a perineal approach decreased (18.3% vs 36.5%) although the use of a perineal procedure in elderly or unfit patients was unchanged (38.5% vs 37.9%). CONCLUSION: The surgical management of external rectal prolapse had changed. More surgeons favoured a laparoscopic abdominal approach in 2014 than in 1997 and the use of perineal approaches had decreased. Of these Delorme's operation remained the most popular but the incidence of the use of Altmeier's procedure had increased.

Major postoperative complications following elective resection for colorectal cancer decrease long-term survival but not the time to recurrence.

AIM: The aim of the study was to determine the effect of major complications after colorectal cancer surgery on survival and time to recurrence. METHOD: Patients having a curative colorectal cancer resection and a follow-up of at least 3 years were identified from a prospective database. Major complications were defined as Clavien-Dindo Grades 3b or 4 and their impact on time to recurrence and mortality was analysed by univariate and multivariable analysis. Postoperative death within 30 days or during the initial hospitalization (Clavien-Dindo Grade 5) was a priori excluded. RESULTS: From 2003 to 2012, 868 colorectal cancer resections resulting in 63 (7%) major postoperative complications including deaths (Clavien-Dindo ≥ 3b) were identified. After exclusion of Grade 5 complications (postoperative or in-hospital deaths), 844 resections with 39 (5%) major complications remained for analysis. Median follow-up time was 5.7 years. Using the Kaplan-Meier method, the estimated crude 5-year overall survival probability was 78% (95% CI 75-81) in the group without and 65% (95% CI 51-83) in the group with major complications (P = 0.009, log-rank test). Major complications were a significant negative predictor for overall survival (hazard ratio 2.42, 95% CI 1.41-4.14) when adjusted for sex, age, American Society of Anesthesiologists grade, tumour site (colon vs rectum), R stage and tumour stage. However, in both univariate and multivariable analysis, major complications were not a significant predictor for time to recurrence (hazard ratio 1.29, 95% CI 0.56-2.99). CONCLUSION: Non-lethal major postoperative complications seem to have a negative long-term impact on survival but not on time to recurrence.

PROSPER: a randomised comparison of surgical treatments for rectal prolapse.

AIM: Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures. METHOD: In a pragmatic, factorial (2 × 2) design trial, patients could be randomised between abdominal and perineal surgery (i), and suture vs resection rectopexy for those receiving an abdominal procedure (ii) or Altemeier's vs Delorme's for those receiving a perineal procedure (iii). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores (Vaizey, bowel thermometer and EQ-5D) measured up to 3 years. RESULTS: Two hundred and ninety-three patients were recruited: 49 were randomised between surgical approaches (i); 78 between abdominal procedures (ii); and 213 between perineal procedures (iii). Recurrence rates were higher than anticipated, but not significantly different in any comparison: Altemeier's vs Delorme's 24/102 (24%) and 31/99 (31%) [hazard ratio (HR) 0.81; 95% CI 0.47, 1.38; P = 0.4]; resection vs suture rectopexy 4/32 (13%) and 9/35 (26%) (HR 0.45; 95% CI 0.14, 1.46; P = 0.2); perineal vs abdominal 5/25 (20%) and 5/19 (26%) (HR 0.83; 95% CI 0.24, 2.86; P = 0.8). Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons. CONCLUSION: No significant differences were seen in any of the randomised comparisons, although substantial improvements from baseline in quality of life were noted following all procedures.

Low rates of local recurrence after surgical resection of rectal cancer suggest a selective policy for preoperative radiotherapy.

AIM: Preoperative short-course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach. METHOD: Analysis was carried out on a prospectively collected unselected series of 1606 patients with rectal cancer treated in one centre. Follow-up was 97% complete. SCRT was performed selectively and all patients had a mesorectal excision. RESULTS: Among 940 patients undergoing a potentially curative major resection the operative mortality was 4.6%, the permanent stoma rate 23% and the crude 5-year survival 61%. The local recurrence rate after curative anterior resection was 2.9% and 7.7% after abdominoperineal excision. The overall local recurrence rate after a potentially curative major resection was 4.0%. CONCLUSION: The routine use of preoperative radiotherapy for rectal cancer is probably not justified where local recurrence after curative rectal resection is uncommon.

Clinical outcome of laparoscopic and open colectomy for right colonic carcinoma.

INTRODUCTION: Laparoscopic colorectal surgery has gained widespread acceptance. While many studies have compared laparoscopic and open left-sided resections, there is limited literature on right colonic resections. We aimed to analyse the short-term outcome of laparoscopic (LRH) and open right hemicolectomy (ORH) in our unit. METHODS: Consecutive patients undergoing elective right hemicolectomies over a period of 28 months were included in the study. No selection criteria were used to allocate the surgical approach. Study parameters included surgical technique, demographic details, ASA grade, body mass index (BMI), length of hospital stay (LOS), post-operative mortality and morbidity, readmission rate and histopathological data. RESULTS: A total of 164 patients underwent right hemicolectomies during the study period (LRH: 89, ORH: 75). Both groups were comparable in age, sex, BMI, ASA grade, tumour stage and lymph node harvest. Four patients (4.5%) in the laparoscopic group required conversion to open surgery. In resections with curative intent, microscopic margins were positive in two patients (3%) in the ORH group compared with one (1%) in the LRH group. Seven ORH patients had an adverse post-operative outcome (three anastomotic leaks, four deaths); there were no deaths/immediate complications in the LRH group (p<0.05). The median LOS for LRH patients (4 days, range: 2-21 days) was significantly shorter than for ORH patients (8 days, range: 3-38 days) (p<0.0001, Mann-Whitney U test). By day 5, 77% of LRH patients were discharged compared with only 21% of patients in the ORH group. There were two readmissions (2.7%) in the ORH group and nine (10.1%) in the LRH group. CONCLUSIONS: Our findings demonstrate advantages in favour of LRH in terms of a shorter hospital stay and reduced post-operative major complications. LRH is safe and should therefore be available to all patients requiring colonic resection.

Simple day-case surgery for pilonidal sinus disease.

BACKGROUND: Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease. METHODS: A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980-2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists. RESULTS: Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment. CONCLUSION: Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease.

Cleft closure for the treatment of pilonidal sinus disease.

AIM: Treatments for pilonidal sinus disease are numerous and prone to failure. In complex disease, the morbidity is high. In contrast with complex operations, the cleft closure procedure can be done simply and successfully with better cosmetic results. We present the results of a single-centre experience of this procedure. METHOD: One hundred and fifty patients had the operation; most were treated as a day case and many were operated under local anaesthetic. RESULTS: Primary healing occurred in 83 (60%) of 139 patients. Recurrences requiring surgery have been seen in 5.3%. The long-term cosmetic appearance has been noted to approach normality. CONCLUSION: Cleft closure is a simple and highly effective operation to treat recurrent or extensive pilonidal sinus disease.

Intradural Extramedullary Sarcoidosis case report and review of literature.

Spinal sarcoidosis represents a rare subgroup of neurosarcoidosis. Most spinal sarcoid lesions are intramedullary, and only a few cases of Intradural Extramedullary (IDEM) sarcoidosis have been reported till date.A thirty years-old female patient with intradural extramedullary sarcoid lesion in the cervico-dorsal spinal canal (C7-D1) without any systemic involvement of sarcoidosis is described. The patient presented with rapidly progressive compressive myelopathy with bladder involvement. She was treated with surgical removal of the lesion coupled with the administration of steroid and showed marked improvement.

Flexible sigmoidoscopy and whole colonic imaging in the diagnosis of cancer in patients with colorectal symptoms.

BACKGROUND: The aim was to identify the patients with colorectal symptoms most likely to benefit from whole colonic imaging (WCI) to diagnose colorectal cancer and those for whom flexible sigmoidoscopy (FS) may be initially sufficient. METHODS: This prospective observational study (16 years) included 16 433 newly referred patients with symptoms or signs of colorectal cancer. RESULTS: Colorectal cancer was diagnosed in 946 patients (diagnostic yield 5.8 per cent), 815 (86.2 per cent) in the rectum or sigmoid (distal) and 131 (13.8 per cent) in the proximal colon. Some 15 829 patients (96.3 per cent) presented with symptoms alone (without iron deficiency anaemia or abdominal mass). Of 787 cancers in these patients, 750 (95.3 per cent) were distal. The prevalence of proximal cancer above and below the age of 60 years was 0.4 per cent (33 of 8249) and 0.1 per cent (four of 7580) respectively. Of 16 256 patients having FS, 5665 (34.8 per cent) had WCI. Of the other 10 591, five subsequently presented with proximal cancers. FS missed ten (1.3 per cent) of 796 cancers. CONCLUSION: Patients with iron deficiency anaemia or a mass require WCI. However, in patients with symptoms alone, FS detects 95 per cent of cancers, and the diagnostic yield of WCI after FS is very low. Alternative management strategies need to be developed to avoid unnecessary investigations in this low-risk group.

National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland.

OBJECTIVE: To assess the safety and short term outcomes of the procedure for prolapsing haemorrhoids (PPH), a relatively new procedure for the treatment of symptomatic haemorrhoids. METHOD: In 2005, the Association of Coloproctology of Great Britain and Ireland set up an online electronic database to audit the indications and outcomes for patients undergoing a PPH procedure. RESULTS: During the audit period, 695 patients were entered onto the database by 61 surgeons (range 1-50 patients per surgeon). The main indications for surgery were bleeding (90.5%) and prolapse (83.9%). Three hundred and ninety-seven (57.1%) patients had grade III or IV haemorrhoids. PPH was performed under general anaesthetic in 602 (86.6%) cases and a consultant surgeon performed the procedure in 572 (82.3%) cases. The median length of stay was 1 day (range 0-6 days). Two hundred and eighty-nine (41.6%) procedures were performed as a day case. Immediate complications were recorded in 75 (10.8%) patients, the commonest being bleeding (21) and urinary retention (24). At 6-week follow-up, 626 (90.1%) patients were pain free. Five patients required hospital re-admission for secondary haemorrhage (3), peri-anal abscess (1) and pain (1). The commonest problems were minor bleeding (48), urgency (22), pain (14), continued prolapse (12) and pruritus (11). Four patients required an open haemorrhoidectomy for persistent symptomatic haemorrhoids. CONCLUSION: Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids with good short-term outcomes. Long-term follow-up is required perhaps through a compulsory national register.