Stomas: ethnicity and quality of life.

AIM: Stoma formation is believed to have a more significant effect on quality of life in Asian patients than in non-Asian patients, but this has never been formally demonstrated. This study examined factors which may influence quality of life following stoma formation with particular reference to ethnicity. METHOD: Quality of life was measured (using an established questionnaire) in consecutive patients undergoing stoma formation under the care of two colorectal surgeons. RESULTS: Quality of life is poorer in Asian than in non-Asian patients 46 ± 13 vs 60 ± 12 (P = 0.007). This difference is restricted to those born outside the UK and to those who cannot speak English (P = 0.0008 and P = 0.0001, respectively). CONCLUSION: The association between stoma formation and poor quality of life in Asian patients is more complicated than previously assumed. Selected patient groups can be targeted with information and support.

Primary anastomosis without colonic lavage for the obstructed left colon.

INTRODUCTION: Resection, on-table lavage (OTL) and primary anastomosis is the treatment of choice for the obstructed left colon. OTL is time-consuming, requires considerable mobilisation/bowel handling, an enterotomy and potentially exposes the patient to mesenteric vascular injury, faecal contamination and a prolonged ileus. We have assessed outcome following primary resection and anastomosis without prior lavage. PATIENTS AND METHODS: Twenty-four consecutive, obstructed patients underwent splenic flexure mobilisation and high anterior resection (concomitant small bowel resection in 2) with primary side-to-side colorectal anastomosis without either prior lavage or covering stoma. Outcome was audited. RESULTS: Twenty-four patients, 17 female aged 48-92 years (median. 76 years) presented with left-sided obstruction due to carcinoma (Dukes' B [3], C [6], D [1]) or chronic diverticulitis (14). Median operative time was 85 min (range, 40-105 min). Colonic ileus resolved on day 2 (29%) and day 3 (58%). Median hospital stay was 7 days (range, 6-72 days); 92% discharged by day 10. There were no deaths or re-admissions. A return to theatre followed a reactionary haemorrhage in one. This latter patient's anastomosis leaked on day 4 (no faecal contamination) and was converted to an end stoma. Urinary and wound infections were seen in two. Late complications comprised two anastomotic strictures; both responded to balloon dilatation at 5 months. CONCLUSIONS: Resection and primary anastomosis without on-table lavage is an easy, practical, predictable and safe treatment option for left-sided colonic obstruction with minimal complications.

Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction.

OBJECTIVE: Whilst trans-abdominal fixation +/- resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve-sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor. METHOD: A prospective database was used to audit our 7-year experience of this technique. The recto-vaginal septum was mobilized anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral promontory. Patients were assessed with questionnaires and Cleveland Clinic scores. RESULTS: Eighty patients, six males, median age 59 years (range 31-90) underwent laparoscopic prolapse surgery between Jan 1997 and Dec 2005; 55% had full thickness prolapse and 46% rectal anal intussusception. Five had a solitary rectal ulcer. A total of 58% had undergone previous surgery; hysterectomy 33%, posterior colporrhaphy 15%, posterior rectopexy 6%, Delorme's rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2-17) and 31% reported symptoms of obstructed defecation; seven had slow transit constipation and underwent resection. The median operative time was 125 min (range 50-210) with one conversion. Median time to diet was 12 h and median length of stay 3 days (1-12). No patient has developed recurrent full thickness prolapse at a median follow-up of 54 months (30-96). Incontinence improved in 39 of 43 patients (91%); median post-operative Wexner score 1 (0-9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence. CONCLUSION: Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium-term, it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.

Laparoscopic appendicectomy: a training model for laparoscopic right hemicolectomy?

OBJECTIVE: To analyse the outcome of laparoscopic appendicectomy and right hemicolectomy and see if the surgical approach to the former can be applied to the latter. METHOD: A prospective electronic laparoscopic database identified 330 appendicectomies and 78 right hemicolectomies (using this approach) between 1996 and 2005. RESULTS: Three hundred and thirty patients (188 males: median age 38 years, range 17-74 years) underwent laparoscopic appendicectomy; 270 (82%) were performed by trainees (higher surgical trainee 71%, basic surgical trainee 12%). The median operative time for trainees was 35 min (14-75 min) with a conversion rate 2%. There were no intra-operative complications. The postoperative complication rate excluding minor wound infection (5.5%) was 1.5%. There were no deaths. The median hospital stay was 2 days (1-15 days). The 30-day readmission rate was 1%. Seventy-eight patients (23-93 years) underwent laparoscopic right hemicolectomy during 2004/5; trainees performed parts thereof in the majority or all of the surgery in 25 cases. The median operation time was 55 min: trainees 115 (65-145 min). There was one conversion. The median hospital stay was 4 days (2-23 days) falling to 3 for the last 20 operations (1-8 days). There were two readmissions for wound sepsis and small bowel obstruction and three deaths (3.8%): anastomotic leak (one), C difficile infection leading to renal failure (one) and duodenal perforation (one). CONCLUSION: Laparoscopic appendicectomy is a safe, predictable, easily learnt operation and an ideal model for learning the skills and principles required for more advanced laparoscopic colorectal interventions and in particular, right hemicolectomy.

Warm ischemic time during laparoscopic live donor nephrectomy: effects on graft function.

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) has become established as a safe and effective alternative to the open procedure. However, the effect of prolonged warm ischemia time (WIT) during retrieval of the kidney remains unclear. The aim of this study was to analyze the effects of WIT on short-term and long-term graft outcomes after LDN. METHOD: In this retrospective analysis of LDN the effects of WIT on delayed graft function, rate of decline in serum creatinine concentration (SCr) in the first 10 days, changes in SCr at 3 months, acute rejection rate changes in Delta creatinine, biopsy-proved chronic allograft rejection and graft survival were assessed according to duration of WIT. Analysis was made by comparing WIT < or =3 versus >3 minutes and WIT <5, 5-10, and >10 minutes. RESULTS: The WIT, which ranged from 1 to 15 minutes, appeared to be related to the learning curve and to technical difficulties. Prolonged WIT did not appear to have an effect on early graft function or the rate of decline in SCr during the first 3 months posttransplantation, but may be associated with an increased rate of acute rejection. Changes in Delta creatinine over time were not affected by the length of WIT during LDN. CONCLUSION: WIT encountered during LDN has no effect on either short-term or long-term graft outcome.

Simple equipment for decompression of the colon during laparotomy for large bowel obstruction.

A simple method is described for decompressing the colon at laparotomy for large bowel obstruction.