Efficacy of the anal fistula plug in complex anorectal fistulae.

OBJECTIVE: The treatment of complex anorectal and rectovaginal fistulae remains a difficult problem. The options are fistulotomy, setons, fibrin glue and a variety of flap procedures. Recently, there have been several reports of a new plug; the Surgisis AFP plug. Reports from various centres do not give consistent results. The aim of this study was to assess the efficacy of the Surgisis AFP fistula plug in a wide spectrum of patients with anorectal, rectovaginal and pouch vaginal fistulae. METHOD: Between March 2006 and September 2007, patients with a variety of anal fistulae were selected for fistula plug insertion in the coloproctology units at Leeds, UK, and Aarhus, Denmark. Demographic and fistulae details were obtained. Postoperatively, all patients had a course of oral antibiotics. RESULTS: Forty-three patients with a median age of 45 (range 18-65) years underwent a total of 45 procedures. Seventy-five per cent (n = 32) had a fistula secondary to cryptoglandular abscess. Median follow up was 47 (range 12-77) weeks. The success rate for complete healing was 44%. Dislodgement caused failure on 10 (22%) occasions. CONCLUSION: Our study shows a moderate success rate for treatment with fistula plugs. The complex nature of the fistulae selected may be the reason for the low success rate.

Retroperitoneal margin involvement by adenocarcinoma of the caecum and ascending colon: what does it mean?

OBJECTIVE: Circumferential margin involvement (CRM) is a powerful predictor of local recurrence, distant metastasis and patient survival in rectal cancer. In this study, we aimed to determine the frequency of retroperitoneal margin involvement in right colon cancer and describe its relationship to tumour stage and outcome of surgical treatment. METHOD: Two hundred and twenty-eight consecutive resections for adenocarcinoma of the ascending colon and caecum were identified between 1998 and 2006. Tumour involvement of the posterior retroperitoneal surgical resection margin (RSRM) was recorded and correlated with tumour stage, grade and clinical outcome. RSRM positive patients were compared with CRM positive rectal tumours resected in the same surgical unit. RESULTS: Nineteen of 228 right hemicolectomies (8.4%) showed tumour involvement of the RSRM (defined as < or = 1 mm). Approximately half of the RSRM positive patients underwent palliative resections because of synchronous distant metastases. Out of nine 'potentially curative' resections where the RSRM was involved, five patients subsequently developed metastatic recurrence and two isolated local recurrence. RSRM positivity was associated with advanced tumour stage and more extensive extramural spread than CRM positive rectal cancers. CONCLUSION: Retroperitoneal surgical resection margin involvement by caecal and ascending colon carcinoma is a marker of advanced tumour stage and associated with a high incidence of synchronous and metachronous distant metastasis. More aggressive surgery to obtain a clear margin or postoperative radiotherapy to the tumour bed is likely to benefit only a minority of patients.

The impact of spontaneous tumour perforation on outcome following colon cancer surgery.

OBJECTIVE: The impact of spontaneous tumour perforation on survival following surgery for colon cancer is unclear. This study compares survival outcomes for patients with perforated colonic cancer with stage-matched nonperforated cancer. METHOD: A prospective histological database was searched for all patients undergoing resection for adenocarcinoma of the colon between 1996 and 2002. Patients with T4 cancer were selected and classified into those with spontaneous perforation at the tumour site and those with nonperforated tumour. Patients with synchronous colonic and rectal cancers, familial polyposis, inflammatory bowel disease, iatrogenic or remote colonic perforation were excluded. Histological variables were combined with clinical data obtained by case note review. Data were analysed for differences in demographics, histological variables, operative mortality, disease-free and overall survival. Multivariate analysis of factors predictive of overall survival in both groups was performed. RESULTS: Of 960 patients identified, 52 patients had spontaneous tumour perforation and 82 patients served as the T-stage matched control group. Overall survival at 2 years was 47% and 54% and at 5 years was 28% and 33% for perforated and nonperforated cancers respectively. Patients with perforated cancers were more likely to present with metastatic disease and undergo emergency surgery with a higher 30-day mortality. There was a trend towards reduced overall survival in the perforated group (P = 0.06), but no difference in disease-free survival (P = 0.43). On multivariate testing, 'emergency surgery' and 'age >75 years' were the only independent predictors of mortality in the perforated and nonperforated group respectively. CONCLUSION: Both perforated and nonperforated T4 colon cancers have a poor prognosis. Spontaneous perforation of the cancer is associated with reduced overall survival, due to higher 30-day mortality, but in itself does not appear to significantly impact on disease-free survival. Rather, it is the advanced oncological stage at which perforated cancers present that determines outcome.

Fate of the inguinal hernia following removal of infected prosthetic mesh.

Open tension-free hernioplasty using a prosthetic mesh is a common operation for inguinal hernia repair because of the relative ease of the operation and low recurrence rate. Wound infection is a potential complication of all hernia repairs and deep-seated infection involving an inserted mesh may result in chronic groin sepsis which usually necessitates complete removal of mesh to produce resolution. Removal of mesh would potentially result in a weakness of the repair and subsequent hernia recurrence. We reviewed the outcome of all our patients who had mesh removal for sepsis over an 8-year period, particularly examining for hernia recurrence and chronic groin pain. This was a retrospective review of the database of patients who had mesh repair of inguinal hernias over an 8-year period. There were 2,139 inguinal hernias repaired using prosthetic mesh. All patients who had mesh removal for infection were identified and followed up. Fourteen patients had deep-seated wound infection which required mesh removal for resolution of sepsis. No peri-operative complications occurred during mesh removal. After a median follow-up of 44 months (range 5-91 months), there were two asymptomatic recurrences and none of the patients had chronic groin pain. Hernia recurrence is uncommon following mesh removal for chronic groin sepsis, suggesting that the strength of a mesh repair lies in the fibrous reaction evoked within the transversalis fascia by the prosthetic material rather than in the physical presence of the mesh itself. When there is established deep infection, there should be no unnecessary delay in removing an infected mesh in order to allow resolution of chronic groin sepsis.

A prospective randomized trial to compare mezlocillin and metronidazole with cefuroxime and metronidazole as prophylaxis in elective colorectal operations.

A prospective randomized trial has compared a broad spectrum ureidopenicillin with a broad spectrum cephalosporin for prophylaxis against the aerobic organisms encountered during elective colonic surgery. Even though only two doses of antibiotics were administered the incidence of severe sepsis was low. Severe wound infection occurred in three of the patients receiving mezlocillin and metronidazole (6 per cent) compared with six in the group receiving cefuroxime and metronidazole (13 per cent). Minor wound sepsis was recorded in 24 per cent of patients receiving mezlocillin and metronidazole compared with only 11 per cent after cefuroxime and metronidazole. There were two episodes of septicaemia, one in each group, and three abscesses, all of which occurred in patients receiving metronidazole and mezlocillin. The total number of surgically related infections was, however, significantly less with cefuroxime and metronidazole (N = 13) compared with mezlocillin and metronidazole (N = 23; P less than 0.03). Escherichia coli was the principal organism responsible for surgically-related postoperative sepsis: (22 isolates: 14 mezlocillin and eight cefuroxime) all of which sensitive to the agents used. Pseudomonas aeruginosa was recovered from 10 patients (three mezlocillin and seven cefuroxime), all of the isolates were resistant to both antibiotics and were associated with severe morbidity. There were 11 isolates of Staphylococcus spp. (nine mezlocillin and two cefuroxime: P less than 0.03). Postoperative diarrhoea occurred in six patients, all were in the group receiving cefuroxime and metronidazole. (Clostridium difficile was recovered from the stool in three of which one was associated with Cl. difficile cytotoxin.)

A high incidence of bleeding is observed in a trial to determine whether addition of metronidazole is needed with latamoxef for prophylaxis in colorectal surgery.

A prospective randomized trial has compared the use of latamoxef sodium (two doses) with latamoxef and metronidazole for elective colorectal surgery. The incidence of wound infection in patients receiving latamoxef alone was 34 per cent compared with 32 per cent in patients receiving latamoxef and metronidazole. Only eight of the 36 wound infections in this study could be classified as major. Only two patients developed an intra-abdominal abscess postoperatively and there was only one episode of septicaemia. Postoperative haemorrhage was recorded in 17 patients (15 per cent). Twelve episodes of bleeding occurred in the first 97 patients who entered the trial and prolongation of the prothrombin time was recorded in eight of 16 patients. In view of these findings 10 mg vitamin K was given with each dose of latamoxef to the last group of patients. However, bleeding occurred in five of 13 patients receiving vitamin K and entry to the study was therefore discontinued.

Treatment of resistant distal intestinal obstruction syndrome with a modified antegrade continence enema procedure.

We report a case of a patient with CF who had a long history of recurrent distal intestinal obstruction syndrome. She had been treated with conventional treatment including gastrografin, n-acetyl cysteine, Klean prep and Picolax. She underwent a modified antegrade continence enema procedure. She currently irrigates her conduit every 2-3 days. She has had no further symptoms of distal intestinal obstruction syndrome.

Monoclonal antibody and cytological detection of free malignant cells in the peritoneal cavity during resection of colorectal cancer--can monoclonal antibodies do better?

Detection of free malignant cells in the peritoneal cavity following curative resections of colorectal cancer may explain why some patients develop local or peritoneal recurrence after favourable operations. We have examined the incidence of peritoneal malignant cells using standard cytological methods and by indirect immunoperoxidase staining using monoclonal antibodies (CEA L11/285/14 and HMFG 1 and 2) in 30 patients having resection for colorectal cancer. Peritoneal washings were collected on opening the peritoneal cavity and immediately prior to closing the abdominal wall following resection. Abnormal cells were only demonstrated in 10 patients. Cytology revealed abnormal cells in seven patients (three preresection and three postresection, one patient had pre- and postresection positive cytology). Monoclonal antibody staining revealed abnormal cells in seven patients (two preresection and four postresection, one patient had both pre- and postresection positive stains). Only two patients had identical results using cytology and antibody staining. Seven of these 10 patients had hepatic metastases. The correlation between the assessment of free malignant cells using cytology and monoclonal antibody staining is poor. Long-term follow-up is required to see if 'free cells' have prognostic significance.

Metronidazole and ticarcillin in the prevention of sepsis after appendicectomy.

Ticarcillin was compared with metronidazole in the prevention of wound infection after appendicectomy. Two hundred nine patients with a diagnosis of acute appendicitis were admitted to a prospective, randomized study and received 500 mg of metronidazole or 5 g of ticarcillin intravenously before operation. Those patients with gangrenous or perforated appendices received two additional doses of the trial drug at 8 hourly intervals. The overall incidence of wound infections in both the metronidazole and the ticarcillin groups was 9 percent. There were no intraabdominal abscesses. Metronidazole abolished anaerobic wound infections. All the early wound infections (between 2 and 4 days after operation) occurred in patients with gangrenous or perforated appendices. We conclude that ticarcillin is as effective as metronidazole in the prevention of wound infection after appendicectomy, but in high-risk patients, (those with gangrenous or perforated appendices) longer courses of antibiotics should be employed.

Hereditary internal anal sphincter myopathy causing proctalgia fugax and constipation: further clinical and histological characterization in a patient.

Hereditary internal anal sphincter myopathy is a very rare condition, only three families have so far been described in the literature. In this case report further clinical and histological findings of one affected member of one of the above families are presented.

Early gastric cancer in a patient with Menetrier's disease, lymphocytic gastritis and Helicobacter pylori.

OBJECTIVE: To describe a patient with early gastric cancer, Menetrier's disease, lymphocytic gastritis and Helicobacter pylori infection. DESIGN: A single patient case report. PATIENT: A 73-year-old man presenting with lower limb deep venous thrombosis was found to have a gastric adenocarcinoma on upper gastrointestinal endoscopy. He subsequently had a total gastrectomy. RESULTS: Histological examination of the resected stomach showed an early gastric cancer and changes typical of Menetrier's disease, lymphocytic gastritis and Helicobacter-associated chronic gastritis. CONCLUSION: This case suggests a link between gastric adenocarcinoma, Menetrier's disease and lymphocytic gastritis. The presence of H. pylori is postulated as a possible aetiology.

An aid to the assessment of bowel preparation prior to colonic resection.

The removal of solid and liquid faeces from the colon is a prerequisite for safe colonic resection. Previous studies attempting to quantify evacuation of the colon have relied on a subjective opinion on isolated areas of the colon at the time of surgery. In an attempt to validate the surgeon's opinion, we have studied the efficiency of bowel preparation in 55 patients undergoing elective surgery requiring bowel preparation. Efficiency of bowel preparation has been assessed by (i) the subjective evaluation of the operating surgeon, (ii) the weight of faecal residue in the resected colon, and (iii) the production of a 'granule index' based upon the removal of Portex granules from the colon by preparation as measured on plain abdominal X-rays before and after preparation. The correlation between weighed faecal residue and the subjective assessment was poor. In 7 of 20 patients assessed subjectively as having no residue, faecal loading was in excess of more than 0.1 g/cm. The surgical assessment did not correlate with the clearance of Portex granules and two patients who had complete clearance of granules were judged poorly prepared. Surgeons are generally poor judges at assessing success or failure of bowel preparation. Standardisation of success of bowel preparation is important in the comparison of clinical trials and Portex granules would appear to give an accurate preoperative assessment of the efficiency of bowel preparation.

Selective salvage surgery in gastrointestinal and gynaecological cancer.

The role of reoperation with intent to excise locally recurrent disease has been evaluated in a selected group of 64 patients originally treated for primary gastrointestinal or gynaecological cancer. In 16 (25%), surgery was successful in eradicating all known sites of disease and was associated with a median survival of 23 months. Patients most suitable for reoperation were those with non-specific gastrointestinal symptoms or asymptomatic local disease. Nevertheless, those with specific symptoms may have treatable local disease or even benign conditions, and thus all with suspected local recurrence should be evaluated with a view to salvage surgery.

The importance of laparotomy in the diagnosis and management of intestinal bleeding of obscure origin.

Thirty-seven patients who had had either a colonoscopy or a selective mesenteric angiogram while being investigated for severe or persistent gastrointestinal bleeding of obscure origin were reviewed. Failure to make a prompt diagnosis was partly responsible for the 16% hospital mortality in the series. Colonoscopy was diagnostic on 6 out of 38 examinations but detected 43% of lesions in the colon. Angiography achieved only 3 diagnoses in 17 examinations. Fourteen patients had an exploratory laparotomy which was diagnostic in 9. We believe that early laparotomy still has an important place in the diagnosis and treatment of intestinal bleeding of obscure origin.

Enterovesical fistulas in Crohn's disease.

A total of 19 enterovesical fistulas were recorded in a series of 799 patients with Crohn's disease (2.4%). The origin of the fistulas was: ileum (9), colon (6) and four were complex involving the small and large bowel. Only 13 patients presented with urinary symptoms: pneumaturia (9), haematuria (1) and urinary tract infection (3). Four fistulas were identified incidentally during contrast radiology, one fistula was identified during a laparotomy and one further fistula developed after a previous resection for Crohn's disease. Four patients were managed conservatively and all are asymptomatic, but it is not known whether the fistula has healed. Twelve fistulas were resected: 9 healed, 2 recurred and 1 patient died following resection for a malignant fistula complicating Crohn's disease. Early in the series three patients were managed by bypass or defunction of the fistula. In all cases the sepsis persisted resulting in mortality. Persistent symptomatic fistulas should be treated by resection of the affected segment of bowel with primary anastomosis if appropriate. The defect in the bladder should be closed over an indwelling catheter which should not be removed until there is radiological confirmation that the bladder defect has healed satisfactorily.

Laparoscopic appendicectomy: calculating the cost.

INTRODUCTION: Laparoscopic appendicectomy is a commonly performed procedure presenting a considerable cost burden. Given the additional operative costs of laparoscopic versus open appendicectomy, it is not clear whether the national tariffs are appropriate for laparoscopic appendicectomy. We conducted a study to establish the institutional costs, and to determine whether re-imbursement according to the national tariffs was sufficient. PATIENTS AND METHODS: Data were collected prospectively on patients undergoing laparoscopic appendicectomy within Leeds Teaching Hospitals Trust. Theatre and bed costs were obtained. Cost analysis was performed, and costs were compared to the re-imbursement due. RESULTS: Fifty laparoscopic appendicectomies were performed. Median operative time was 60 min. The median total operative cost of laparoscopic appendicectomy was pound906. Median equipment cost for laparoscopically completed cases was pound254. Median total in-patient cost was pound1617 (range, pound880- pound3360). This compared with a mean re-imbursement of pound1981 representing a cost benefit of pound233 per case (P = 0.0009). CONCLUSIONS: Despite a liberal use of disposable equipment, laparoscopic appendicectomy can still be performed within the confines of the national tariffs. There is a considerable variation in the cost of this procedure, and it may be possible to reduce costs by more stringent use of disposable equipment and standardising recovery protocols.

A case of Sister Mary Joseph nodule associated with primary gastric lymphoma.

The Sister Mary Joseph nodule is a peri-umbilical metastasis most commonly found with adenocarcinomas of the gastrointestinal tract and ovary. It was first described 140 years ago but has not previously been reported in association with primary gastric lymphoma.