Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: still the way to go?

Laparoscopic ventral mesh rectopexy (VMR) has become a popular surgical technique for treating women with full-thickness rectal prolapse with a low recurrence rate, as demonstrated by several studies. In addition, it is increasingly applied to female patients with obstructive defecation syndrome (ODS) caused by intussusception ± rectocele. Functional improvement can be achieved in a high number of patients with ODS, but expectations need to be discussed carefully, as a few patients may not benefit at all. In particular, long-term data on functional outcome and complications following laparoscopic VMR for ODS are still lacking in the literature. Notably, laparoscopic VMR appears to be better than alternative operations for prolapse, intussusception, and rectocele in terms of efficacy, recurrence rates, and adverse effects, but there is a lack of evidence directly comparing techniques through randomized controlled trials; thus, its exact role stills needs to be defined in the future.

Mercaptopurine versus placebo to prevent recurrence of Crohn's disease after surgical resection (TOPPIC): a multicentre, double-blind, randomised controlled trial.

BACKGROUND: Up to 60% of patients with Crohn's disease need intestinal resection within the first 10 years of diagnosis, and postoperative recurrence is common. We investigated whether mercaptopurine can prevent or delay postoperative clinical recurrence of Crohn's disease. METHODS: We did a randomised, placebo-controlled, double-blind trial at 29 UK secondary and tertiary hospitals of patients (aged >16 years in Scotland or >18 years in England and Wales) who had a confirmed diagnosis of Crohn's disease and had undergone intestinal resection. Patients were randomly assigned (1:1) by a computer-generated web-based randomisation system to oral daily mercaptopurine at a dose of 1 mg/kg bodyweight rounded to the nearest 25 mg or placebo; patients with low thiopurine methyltransferase activity received half the normal dose. Patients and their carers and physicians were masked to the treatment allocation. Patients were followed up for 3 years. The primary endpoint was clinical recurrence of Crohn's disease (Crohn's Disease Activity Index >150 plus 100-point increase in score) and the need for anti-inflammatory rescue treatment or primary surgical intervention. Primary and safety analyses were by intention to treat. Subgroup analyses by smoking status, previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis were also done. This trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN89489788) and the European Clinical Trials Database (EudraCT number 2006-005800-15). FINDINGS: Between June 6, 2008, and April 23, 2012, 240 patients with Crohn's disease were randomly assigned: 128 to mercaptopurine and 112 to placebo. All patients received at least one dose of study drug, and no randomly assigned patients were excluded from the analysis. 16 (13%) of patients in the mercaptopurine group versus 26 (23%) patients in the placebo group had a clinical recurrence of Crohn's disease and needed anti-inflammatory rescue treatment or primary surgical intervention (adjusted hazard ratio [HR] 0·54, 95% CI 0·27-1·06; p=0·07; unadjusted HR 0·53, 95% CI 0·28-0·99; p=0·046). In a subgroup analysis, three (10%) of 29 smokers in the mercaptopurine group and 12 (46%) of 26 in the placebo group had a clinical recurrence that needed treatment (HR 0·13, 95% CI 0·04-0·46), compared with 13 (13%) of 99 non-smokers in the mercaptopurine group and 14 (16%) of 86 in the placebo group (0·90, 0·42-1·94; pinteraction=0·018). The effect of mercaptopurine did not significantly differ from placebo for any of the other planned subgroup analyses (previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis). The incidence and types of adverse events were similar in the mercaptopurine and placebo groups. One patient on placebo died of ischaemic heart disease. Adverse events caused discontinuation of treatment in 39 (30%) of 128 patients in the mercaptopurine group versus 41 (37%) of 112 in the placebo group. INTERPRETATION: Mercaptopurine is effective in preventing postoperative clinical recurrence of Crohn's disease, but only in patients who are smokers. Thus, in smokers, thiopurine treatment seems to be justified in the postoperative period, although smoking cessation should be strongly encouraged given that smoking increases the risk of recurrence. FUNDING: Medical Research Council.

Challenges of war surgery in Mallavi, Sri Lanka.

Northern Sri Lanka has been separated by an active front line from the remainder of the country and has lacked basic facilities, including hospital care, because of the war between the government and the Tamil Tigers. This article reports on the resulting situation in one district hospital in the region and on the work of Médecins sans Frontières in providing specialist hospital care under such difficulties.

Obstetrics during Civil War: six months on a maternity ward in Mallavi, northern Sri Lanka.

A long-term, large-scale ethnic armed conflict continues in Sri Lanka, where militant separatists control a northern section of the island. The conflict has resulted in a large population of internally displaced persons and a shortage of medical staff. Drug and equipment shortages compound the difficulty in access to medical care. This article reports the experiences from 1 November 2000 to 30 April 2001 recorded by review of medical records and by interviews, in the peripheral unit, in a separatist controlled area of the Mallavi maternity ward. There were 704 births. Most of the mothers had been displaced by the war (69.5 per cent) and had experienced food shortage (67.5 per cent). Referred patients (18.1 per cent) had a high rate of caesarean section (44.3 per cent) and had travelled a mean of 57.6 km to reach Mallavi. There had been substantial antenatal care (94.0 per cent), tetanus toxoid vaccination (95.1 per cent) and malaria prophylaxis (86.4 per cent). Risk factors for low birth weight included a maternal body mass index less than 19 (RR 1.55, CI 1.11-2.16, P = .011), primiparity (RR 1.44, CI 1.05-1.97, P = .024) and self-reported malarial infection during pregnancy (RR 1.42, CI 1.03-1.97, P = .036). Rates of low birth weight, stillbirths, neonatal deaths and maternal mortality in the Mallavi units were higher than the Sri Lankan national averages. Improvements in quality of care and access to health care are unlikely while the war continues.