Department Of Colorectal Surgery Research Articles

Comfort During Digital Rectal Examination - Patient Preference.

The sex and age of the physician performing the digital rectal examination (DRE) procedure is one of the parameters influencing patients' comfort. It is postulated that the stress related to DRE during admission to the surgical ward may affect the compliance. The aim of the study was to characterize patients' preferences according to their sex, age, socioeconomic status and according to DRE-related variables. Patients admitted to the Department of General and Colorectal Surgery at Medical University in Łódź between October 2014 and June 2015 were asked to complete a questionnaire regarding their sex, age, ethnic background, socioeconomic status and preference for a physician performing the DRE during admission to the surgical ward. The study enrolled 225 patients, 52% (n=117) women and 48% (n=108) men. Most patients 73.3% (n=244) expressed no preference for sex of the physician performing the DRE during admission, while 22.7% (n=51) preferred a same-sex physician. Analysis showed that the age, female sex, lower education status, small amount of comorbidities and number of hospitalizations, and no previous colonoscopy experience were all associated with preference for a same-sex physician. In our study most patients expressed no preference for sex of the physician performing the DRE during admission to the surgical ward. However, over one-tenth of patients reported such preferences. Most of these patients preferred a same-sex physician. It is important to offer these patients the choice of physician performing the DRE. Addressing patients' preferences may improve the atmosphere in the clinical environment, reduce stress, and facilitate better treatment.

Expression of the PLS3 Gene in Circulating Cells in Patients with Colorectal Cancer.

Circulating tumor cells (CTC) are cells in circulating blood that have the antigen and gene features of tumor cells of a specific type. Since they can be potentially used in diagnostics and monitoring of treatment of many tumors, they have been attracting attention of researchers worldwide. Plastin-3 (PL S3) is one of such markers of CTC. The aim of the study was to assess expression of PL S3 in CTC in patients with colorectal cancer, to conduct a statistical analysis and to demonstrate a link between expression of PL S3 and progress of the disease, level of CEA and Ca19-9 markers, gender and age of the patients. A group of 85 patients of the Department of General and Colorectal Surgery of the Medical University in Łódź were enrolled in this study. Circulating tumor cells were isolated from whole blood of patients with colorectal cancer and an analysis of PL S3 gene expression in CTC was conducted. The next step was to conduct a statistical analysis and to demonstrate a link between expression of PL S3 in patients' CTC and progress of the disease, level of CEA and Ca 19-9 markers, gender and age of the patients. PL S3 is a marker which can be potentially used in prediction and monitoring of colorectal cancer. A link between expression of PL S3 in CTC of patients with colorectal cancer and metastasis to lymph nodes has been demonstrated. It may be of key importance how PL S3 could impact the qualification to supplementary cancer treatment in patients with stage II colorectal cancer. A link between expression of PL S3 gene in CTC and gender requires further in-depth studies. It is beyond doubt that PL S3 must be further investigated to determine its role in diagnostics, prediction, treatment and monitoring of treatment of colorectal cancer.

Ventral mesh rectopexy: is this the new standard for surgical treatment of pelvic organ prolapse?

Cleveland, Ohio Financial Disclosure: None reported. Correspondence: Brooke Gurland, M.D., Department of Colorectal Surgery, Cleveland Clinic Foundation, Mail Code A30, 9500 Euclid Ave, Cleveland, OH 44195. E-mail: [email protected]

Colonoscopy is the first choice for early postoperative rectal anastomotic bleeding.

BackgroundAnastomotic bleeding is rare but is one of the dangerous complications, with associated morbidity and mortality, at the early stage of rectal cancer surgery. The aim of this study was to report our experiences in the treatment of this emergency condition.MethodsWe retrospectively analyzed the general characteristics, treatment and outcome of patients with severe anastomotic bleeding after undergoing rectal cancer resection with stapled anastomosis at the Department of Colorectal Surgery of Changhai Hospital (China) between January 2011 and December 2013.ResultsAnastomotic bleeding occurred in six out of 2,181 patients (0.3%) who underwent anterior resection with stapled anastomosis due to rectal cancer. All patients’ bleeding was stopped with colonoscopic techniques. There were no anastomotic leakages or strictures in these six patients.ConclusionsAnastomotic bleeding was a very rare complication after rectal cancer resection with stapled anastomosis. Colonoscopic treatment, including electrocoagulation and clipping, were both safely and effectively used in the early postoperative period to cease persistent anastomotic bleeding.

Surgical approach to inflammatory bowel disease in Tayside, east of Scotland

s / International Journal of Surgery 12 (2014) S13eS117 S29 Conclusions: The data shows that higher values of faecal calprotectin correspond to an increased degree of mucosal inflammation. 0602: APER IN A DISTRICT GENERAL HOSPITAL e SHOULD WE BE DOING MORE? Adenike Odeleye, Simran Choudary, Henry Lee, O.A. Lalude, S. Vivekanandan. Princess Alexandra Hospital, London, UK. Introduction: Appropriate surgical management of rectal cancer is crucial to survival. The decision for abdominoperineal excision of rectum (APER) goes against surgical inclinations to engineer an anastomosis with a low anterior resection (LAR). Inappropriately optimistic surgical decisions are known to foster high local recurrence rates and poor overall survival. We aimed to inspect the APER rate and outcomes of patients with rectal cancer in our centre. Methods: A prospectively maintained departmental database was interrogated to determine all patients undergoing AR or APER between 1/1/ 2008-31/12/2010. Recurrence was identified on post-operative CT scans at 2 years. Results: Patients underwent an APER 16% n1⁄414 or AR 84% n1⁄469. The overall average age was 71. Male to Female ratio 1.6:1. One of the LAR patients had local recurrence (1.5%) at 2years whilst there was no evidence of recurrence in the APER group. Distant metastases were identified in 14% of the APER group vs. 5.9% in the LAR group. Nil significant difference in recurrence rates (P-value <0.05). Conclusions: Our centre's APER rate of 16% is favourably comparable to the established literature recommending <30%. The surgical rationale in our unit is supported by the low and comparable risk of recurrence for both LAR and APER at 2 years. 0616: SURGICAL APPROACH TO INFLAMMATORY BOWEL DISEASE IN TAYSIDE, EAST OF SCOTLAND Omar Ashour, Dorin Ziyaie. Ninewells Hospital, Dundee, UK. Introduction: To investigate the surgical approach to IBD in Tayside and to compare it with literature findings. This will hopefully help to elucidate the gold standard operations in the management of IBD and its true extent in practice. Methods: 97 patient notes from Medical-Records were systematically reviewed. A standard template was used to collect certain information, e.g. diagnosis, part of bowel affected, surgical treatment, complications, and functional outcome. Results: The most common type of surgery performed in CD was a right hemicolectomy, RHC (64.9%), followed by a subtotal colectomy, STC (24.6%).Complications such as strictures (18.6%), adhesions (8.1%), perforation (5.4%) and obstruction (5.4%) affected the outcome in RHC, but not STC. With RHC, disease recurrence and re-operation rates were 35.1% and 51.4% respectively compared to 14.2% and 35.7% with STC. UC patients; 92.3% underwent STC-with-end-ileostomy. Following STC, twothirds had either IPAA (64.7%) or TPC (35.3%). Complications with IPAA included pouchitis (36.4%), sepsis (18.2%), pouch failure (16.7%) and haemorrhage (16.7%), whereas an ileostomy only had wound infection (16.7%). Conclusions: Segmental resection in CD has been controversial as it carries a higher recurrence-rate but has all the functional benefits of colonic preservation. STC has higher complication rates compared to RHC from sepsis, wound infection and poor stoma function. Despite complications, IPAA still offered the closest thing to faecal continuity without the use of a stoma bag. 0621: ACTIVATED SYSTEMIC INFLAMMATORY RESPONSE AT DIAGNOSIS REDUCES LYMPH NODE COUNT IN COLONIC CARCINOMA Brenda Murphy, Rory Kennelly, Hamad Yousef, Paul McCormick, Brian Mehigan. Department of Colorectal Surgery, St. James' Hospital,

Audit of emergency laparotomy undertaken at the royal derby hospital compared to the results of the UK emergency laparotomy network; do we meet the optimum standards of care?

s / International Journal of Surgery 12 (2014) S13eS117 S89 0031: AUDIT OF EMERGENCY LAPAROTOMY UNDERTAKEN AT THE ROYAL DERBY HOSPITAL COMPARED TO THE RESULTS OF THE UK EMERGENCY LAPAROTOMY NETWORK; DO WE MEET THE OPTIMUM STANDARDS OF CARE? Aimee Rowe , Sarah Shore, Brett Doleman, David Mulvey, Mike Bewick. Royal Derby Hospital, Derby, UK. Introduction: To compare our performance locally at The Royal Derby Hospital against the recently published National Emergency Laparotomy Audit by the Emergency Laparotomy Network. Methods: Prospective data were collected over a three month period, totalling 85 patients undergoing emergency laparotomy. Data included grade of surgeon and anaesthetist, time of procedure and post-operative destination, and 30 day mortality figures. Results: Mortality locally was similar in all the age groups compared with NELA (P>0.05). Overall 30-day mortality was 14% in the local audit versus 14.9% nationally. Factors found to affect 30-day mortality ranged from underlying pathology to the timing of surgery, with a higher mortality of 20% for the 27/85 cases undertaken ‘out of hours' (00:00-07:59) compared with 10% ‘in hours' (08:00-17:59). Mortality appears to correlate with involvement of consultant anaesthetists/surgeons as more were present ‘in hours'. Post-operative destination was highlighted locally as an area for improvement; 30-day mortality was 17% for patients returning to ICS level 0 care, versus 10% (level 1/2) and 16% (level 3). Conclusions: This study gave insights into current local management of a particularly high-risk patient group. Improved utilisation of critical care units and outreach teams in support of such patients has resulted from this audit. 0274: ROTATIONAL THROMBOELASTOMETRY (ROTEM) e THE FUTURE OF HAEMOSTATIC RESUSCITATION IN MAJOR TRAUMA CENTRES Ruth Bird , James Lawless, Ross Davenport, Claire Rourke, Anne Weaver, Karim Brohi, Daniel Nevin. Royal London Hospital, London, UK. Introduction: Major trauma haemorrhage and coagulopathy are significant factors contributing to early mortality. Routine coagulation testing reflects the initiation phase of haemostasis at the point of testing and is limited in guiding real-time blood product replacement. ROTEM is a point of care test, which measures the interactions of coagulation factors, inhibitors and cellular components during the phases of clotting. It identifies coagulopathies secondary to dilution, consumption, deficiencies and hyperfibrinolysis, providing a rapid guide to haemostatic resuscitation. Methods: Training was initiated in machine use and result interpretation. We devised and implemented a standard operating procedure and robust algorithm, simplifying ROTEM interpretation and blood product replacement therapy into binary steps. Results: The Royal London Hospital Trauma Service introduced ROTEM for “CODE RED”, haemodynamically unstable patients. Creation of a mobile point-of-care unit allows the machine to follow the patient on their journey from admission to intervention. An algorithmic approach to targeted factor replacement therapy has allowed for rapid, widespread utilisation of this technology. Conclusions: Choosing a targeted population of personnel to train, and using a simple algorithmic approach to interpretation and therapeutic decision making; ensures the process is straightforward and easy to utilise when introduced to a major trauma centre. 0326: RE-AUDIT OF TIMELINESS TO EMERGENCY SURGERY: ARE WE MEETING RCS STANDARDS? Hannah Boyd-Carson , Andrew Cheah, Jenny Cole, Chris Horner, Umar Shariff, Haney Youssef. Department of General & Colorectal Surgery, Good Hope Hospital, West Midlands, UK. Introduction: A prospective audit on ”timeliness-to-surgery” for general surgical emergency patients was performed in a district general hospital (July 2012). This demonstrated deficiencies in emergency theatre access compared to RCS recommendations. Following introduction of pre-operative risk stratification and dissemination of audit findings, the aim of this re-audit was to establish if there were improvements in emergency surgical care with respect to RCS standards. Methods: Data on emergency admissions requiring surgical intervention was prospectively collected (1/2/13 3/3/13). Patients were risk stratified for morbidity/mortality rates using P-POSSUM scoring and compared to RCS “timeliness-to-surgery” standards. Results: 53 operations were performed (28% of admissions). Median age 38 years (18-86) with 5.6% post-operative mortality.100% “on-going haemorrhage” and “septic shock” patients went to theatre immediately and within 3 hours respectively; 75% “severe sepsis” patients went to theatre within 6 hours, and 68% “septic” patients went to theatre within 18 hours. Other specialities utilising theatre (30%) and recovery issues (40%) accounted for the main reasons for delays to theatre. Conclusions: Implementation of changes has led to some improvements in timeliness-to-surgery; however two standards were still not met. “Single speciality” theatre allocation and increased recovery staff numbers could potentially improve the delivery of emergency surgical care. 0335: THE LEARNING CURVE OF LAPAROSCOPIC APPENDICECTOMY Wesley Lai , Shelly Griffiths, Stephen Mitchell. South Devon NHS Trust,

Actual versus estimated length of stay after colorectal surgery: which factors influence a deviation?

BackgroundThe aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups. MethodsA cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009. ResultsFor 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ≤ .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS. ConclusionsAfter colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance.

The Efficacy of Endoanal Sonography in Treatment of Patients with Anal Diseases Referred to Shiraz Colorectal Surgery (SCRS) Department Since 2011

Background/Objectives: Different diagnostic modalities have been used in treatment of patients with anal diseases who have referred to Shiraz colorectal surgery (SCRS) department in the past 7 years. These modalities include anoscopy, manometry, endoanal sonography, MRI and EMG in addition to clinical evaluation. Among these modalities, endoanal sonography looks like the first choice of SCR surgeons, and with their increasing reliance on ultrasound findings, the rate of using other modalities have declined among in recent years. Patients and Methods: To evaluate the efficacy of endoanal songraphy on treatment planning of patients with anal diseases, we reviewed the notes of patients who had anal sonography prior to treatment by using Medtronic 360 degree endoanal sonography device. We focused on decision making efficacy of this modality and its diagnostic accuracy. Results: Endoanal sonography was done in 1418 patients from March 2011 to December 2013. In 83% of patients anal canal structure was normal, and in 17% of patients, pathological findings such as anal canal tumor, peri-anal fistula and anal sphincter muscle damage were found. Comparing to other modalities, endoanal sonography had most accuracy in diagnosis of patients with fecal incontinence and was very helpful for colorectal surgeons in decision making for patients with anal canal tumors. In 5 patients with anal canal tumor, primary decision of local excision was changed to AP resection because of detecting T2 or T3 involvements. In 2 patients who insisted on local excision, deep tissue involvement was revealed on histopathology. In patients with incontinence due to sphincter damage, the detected site of damage was accurate in 100% of patients, and colorectal surgeons could confidently rely on sonography findings for approach to the site of sphincter defect. In 15 patients with longstanding anal pain, a small peri-anal cold abscess was detected on endoanal sonography. These abscesses had not been diagnosed prior to ultra sound scanning and were eventually approached and treated under the guide of sonography. Conclusion: Endoanal sonography can be the best modality in detection of anal canal diseases if there is close cooperation between radiologists and colorectal surgeons.

Achieving a Complete Colonic Evaluation in Patients With Incomplete Colonoscopy Is Worth the Effort

Patients with an incomplete colonoscopy are potentially at risk for missed lesions. The purpose of this work was to identify the percentage of patients completing colonic evaluation after incomplete colonoscopy, the manner in which the evaluation was completed, and the incidence of significant pathology. This was a retrospective analysis of prospectively collected data. The study was conducted in an outpatient colonoscopy clinic in the colorectal surgery department of a tertiary referral center. Patients included those undergoing incomplete colonoscopy from a database of 25,645 colonoscopies performed from 1982 to 2009. Procedures aimed at completing colorectal evaluation were included in the study. Reason for incompletion, secondary study, its success, and findings were measured. A total of 242 patients with incomplete colonoscopies were identified; 166 (69%) were women. The average age of patients was 59 years. Most frequent causes for incomplete colonoscopy were inadequate preparation (34%), pain (30%), and tortuosity (20%). The scope could not pass the splenic flexure in 165 patients (71%). A total of 218 patients (90%) were offered completion studies, and 179 patients (82%) complied. Seventy-three of 82 patients who had a surveillance colonoscopy had a follow-up (89%), compared with 72 (87%) of 83 with symptoms and 40 (74%) of 54 who had a screening. Barium enema (BE) was performed in 74 (41%), repeat colonoscopy in 71 (40%), CT colonography in 17 (9%), and colonoscopy under general anesthesia in 9 patients (5%). Resection with intraoperative/perioperative colonoscopy was required in 8 patients (4%). Repeat colonoscopy found 32 lesions (24 tubular adenomas, 4 tubulovillous adenomas, and 4 sessile serrated polyps) in 17 patients (24%). Radiology demonstrated new abnormalities in 11 (12%) of 91 patients, prompting 7 colonoscopies. In 3 patients, colonoscopy showed an inverted appendix, a tubulovillous adenoma, and a sigmoid stricture. Overall, clinically significant lesions were found in 19 patients (10%). This study was limited by an incomplete colonoscopy subjectively determined at the time of colonoscopy, as well as by a lack of comparison group. Complete colonic evaluation in patients with an incomplete colonoscopy is important. Repeat colonoscopy may be the most efficient way to achieve this.

Venous thromboembolism in colorectal surgery: skip SCIP or comply?

The Surgical Care Improvement Project (SCIP) includes recommendations for mechanical and pharmacologic venous thromboembolism (VTE) prophylaxis after colorectal surgery. Compliance with these recommendations is publicly reported and included in current pay for performance plans. Presently, there is limited evidence to support compliance with these recommendations. To determine the incidence of venous thromboembolic events in colorectal surgery patients who did or did not receive the recommended pharmacologic prophylaxis. We performed a retrospective analysis of prospectively accrued data from a single-center, tertiary care, colorectal surgery department. The main outcome measure was the occurrence of venous thromboembolic events and the need for blood transfusion after surgery. Of 674 patients, 613(91%) received the recommended pharmacologic VTE prophylaxis and 61 (9%) did not. Diagnosis, patient variables, and type of surgery performed were similar in each group while operative time was increased in the compliant group (251 vs. 194 min, p < 0.05). In the compliant and noncompliant groups, the incidence of extremity deep venous thrombosis was 2.8 and 8.2% (p = 0.04), the incidence of pulmonary embolus 1.1 and 3.3% (p = 0.19), the incidence of portomesenteric venous thrombosis 2.6 and 4.9% (p = 0.38), and the incidence of any VTE 5.4 and 13.1% (p = 0.02), respectively. The use of perioperative red blood cell transfusions in the two groups was 9.1 and 14.8%, p = 0.17. In the subgroup analysis of open cases, there were no statistical differences in the occurrence of any type or combination of VTE. Compliance with SCIP recommendations for pharmacologic VTE prophylaxis decreased the incidence of VTE after colorectal surgery with no increase in the use of perioperative transfusion. Colorectal surgeons who elect to skip these recommendations may jeopardize both the reputational score and financial reimbursement of their hospital and may put their patients at unnecessary risk for a preventable postoperative complication.

Aidi injection combined with FOLFOX4 chemotherapy regimen in the treatment of advanced colorectal carcinoma.

The aim of this retrospectively study was to evaluate the clinical efficacy of Aidi injection (ADI) combined with FOLFOX4 chemothreapy regimen in the treatment of advanced colorectal carcinoma. One hundred and twenty one patients with pathology confirmed advanced colorectal carcinoma were retrospectively analyzed in the department of colorectal surgery in Union Medical Center, Tianjin (UMC). Of the included 121 cases, 58 subjects received the treatment of ADI combined with FOLFOX4 chemotherapy (experiment group) and the other 63 cases received the FOLFOX4 chemotherapy alone (control group). After two cycles chemotherapy treatment, the short-term clinical efficacy such as complete response (CR), partial response (PR) and objective response rate (ORR) were compared between the two groups. The quality of life improvement and chemotherapy related toxicity were also recorded and analyzed. The response rate including CR, PR and ORR were not statistical different between the experiment group and control group (P > 0.05); The KPS score was significant decrease in the control group compared to that in experiment group (P < 0.05); The risk of developing grade-II nausea vomiting and diarrhea was much lower in experiment than that in control group (Pall < 0.05). ADI combined with FOLFOX4 chemotherapy can improve the quality of life and decrease some of the toxicity related to chemotherapy in patients with advanced colorectal cancer.

Ultraradical Resection for Locally Recurrent Rectal Cancer

Leeds, United Kingdom Financial Disclosure: None reported. Correspondence: Peter M. Sagar, M.D., F.R.C.S., The John Goligher Department of Colorectal Surgery, St James’s University Hospital, Leeds, UK LS7 9TF. E-mail: [email protected]

Impact of Stress Dose Steroids on the Outcomes of Restorative Proctocolectomy in Patients With Ulcerative Colitis

Stress dose steroids are administered during the perioperative period to prevent complications of secondary hypoadrenalism, which can occur after long-term steroid treatment. Steroids also increase postoperative morbidity. Patients with ulcerative colitis often require steroid therapy before definitive surgery and often receive perioperative steroids in a variety of doses. The aim of this study was to evaluate the impact of stress dose steroid administration on short-term postoperative outcomes after restorative proctocolectomy in patients with ulcerative colitis. This was a retrospective cohort study. The investigation took place in a high-volume, specialized colorectal surgery department. Patients who had been treated with steroids for ulcerative colitis and underwent a restorative proctocolectomy from January 2009 to July 2011 were identified and categorized into 2 groups based on whether they received stress dose steroids. Both cohorts were compared for patient demographics, duration of steroid treatment before surgery, and operative and postoperative outcomes. Eighty-nine patients received stress dose steroids and 146 patients did not. Stress dose steroids were more frequently administered to patients who were under steroid treatment immediately before restorative proctocolectomy (37.1% versus 10.3%; p < 0.001). A sinus tachycardia developed more frequently in patients who received stress dose steroids during surgery (p = 0.03). One patient in the stress dose steroid group died on postoperative day 25 because of anastomotic leak. Although no patients in either group had an adrenal crisis during surgery, 1 patient in the stress dose steroid group was diagnosed with adrenal insufficiency postoperatively. This study was limited by its retrospective and nonrandomized nature. Although administration of stress dose steroids is not related to increased postoperative complications, the steroids do not appear to affect adrenal insufficiency outcomes. Patients who were treated with steroids for ulcerative colitis should be monitored carefully in the perioperative and early postoperative periods for signs of adrenal insufficiency, regardless of the steroid regimen used.

Stapled Versus Hand-Sewn Anastomosis in Colorectal Cancer Surgery : A comparative study

Introduction: In spite of long journey of intestinal anastomotic techniques surgeons still are not free from doubt about the leakage after colorectal anastomosis. In distal rectal anastomosis after cancer surgery it poses more risk due to poor colonic vascularity and reduced remaining tissue to nourish the anastomotic site. Exploration of surgical staplers has provided some procedural advantages and sense of security to surgeons as well as to patients in respect to sphincter saving and thereby improving quality of life. However, outcome measures of these devices should be made to see its efficacy over conventional hand-sewn technique because their cost play role in treatment plan. The result of such comparative study may help surgeons to counsel the patients. Objectives: To find out whether stapled anastomosis is safer than hand-sewn anastomosis in colon and rectal cancer surgery. methods: The quasi-experimental study was undertaken in the department of general and colorectal surgery, Bangabandu Sheikh Mujib Medical University hospital during Feb 2005 to June 2008. Total 100 patients were selected. 48 patients underwent ‘Stapled’ and 52 underwent ‘Hand-sewn’ anastomosis. The patients were treated and postoperatively managed by same colorectal surgeon. The outcome variables were ‘time required for anastomoses, ‘postoperative hospital stay’ and early and late ‘complications’ in postoperative and follow-up period. Result and observation: The age, sex, socioeconomic status or co-morbidities did not show any statistical difference between two groups as in the hospital stay (p=.821). The time required for anastomosis showed strongly significant difference (18.17 min and 26.85 min; p=.000) in favor of stapling group. The hemorrhage from anastomotic line (p=1.00), anastomotic leakage (p=.413), ileus/ obstruction (p=.640) and wound dehiscence (p=.640) were much less in stapled group though they lack statistical power. All others except anastomotic stenosis (p=.514) showed almost similar results. Conclusion: Considering user perspective, time requirement and postoperative complications stapling technique appear to be safer and superior to hand-sewn technique though it demands statistical strengthening on large scale study. Chattagram Maa-O-Shishu Hospital Medical College Journal Volume 12, Issue 3, September 2013: 56-61

The role of endorectal ultrasound in the management of rectal lesions in a tertiary centre

s / International Journal of Surgery 11 (2013) 589e685 623 ABSTRACTS Aims: This study aims to establish the risk factors present in a cohort of patients with grade 3 anal intraepithelial neoplasia (AIN3) and the rate of progression to anal squamous cell carcinoma (SCC). Methods: Patients with a histological diagnosis of AIN3 in Cardiff and Vale NHS trust between 2007 and 2012 were reviewed. Results:26patientswere identifiedwithamean followupof3years.11 (42%) presented with SCC on a background of AIN3, 15 (58%) with AIN3. 73% of patients were current or ex smokers. Of patients presenting with AIN3, 7 (47%) reported previous anogenital warts and 3 (20%) were HIV positive. 6 women (35%) had concurrent genital intraepithelial neoplasia (4 cervical, 1 vulval, 1 vaginal). 1 patient (4%) was immunosuppressed after a renal-allograft.10patientsunderwent chemo-radiotherapy for SCC,withno recurrence of AIN3whilst 1 died ofmetastatic disease. 60% of AIN3patientswere disease freeat the timeof thestudyafter local excision.The rateofprogressionofAIN3 to SCC was 20% despite on-going surveillance and treatment. Conclusion: The cohort demonstrated known risk factors for AIN3 and showed a rate of progression to SCC higher than previously reported. 0588: FACTORS PREDICTIVE OF WOUND INFECTION IN A COLORECTAL UNIT. A CASE-CONTROL STUDY Catherine Power, Mike Davies, Rachel Hargest, Simon Phillips, Chris Morris. Department of Colorectal Surgery, University Hospital of Wales,

Liposome bupivacaine (EXPAREL&amp;reg;) for extended pain relief in patients undergoing ileostomy reversal at a single institution with a fast-track discharge protocol: an IMPROVE Phase IV health economics trial

BackgroundPostoperative opioid use following ileostomy reversal procedures contributes to postoperative ileus. We assessed the impact of a liposome bupivacaine-based, opioid-sparing multimodal analgesia regimen versus a standard opioid-based analgesia regimen on postsurgical opioid use. We also assessed health economic outcomes in patients undergoing ileostomy reversal at our institution, which employs an enhanced recovery discharge protocol.MethodsIn this single-center, open-label study, patients undergoing ileostomy reversal received postsurgical pain therapy via multimodal analgesia that included a single intraoperative administration of liposome bupivacaine or opioid-based patient-controlled analgesia (PCA) with intravenous morphine or hydromorphone. Rescue analgesia (intravenous [IV] opioids and/or oral opioid + acetaminophen) was available to all patients. Primary efficacy measures included postsurgical opioid use, hospital length of stay (LOS), and hospitalization costs. Secondary measures included: time to first rescue opioid use; patient satisfaction with analgesia; additional medical intervention; and opioid-related adverse events.ResultsForty-three patients were enrolled and met eligibility criteria (IV opioid PCA group = 20; liposome bupivacaine-based multimodal analgesia group = 23). Postsurgical opioid use was significantly less in the multimodal analgesia group compared with the IV opioid PCA group (mean [standard deviation]: 38 mg [46 mg] versus 68 mg [47 mg]; P = 0.004). Postsurgical LOS between-group differences (median: 3.0 days versus 3.8 days) and geometric mean hospitalization costs (US $6,611 versus US$6,790) favored the multimodal analgesic group but did not achieve statistical significance. Median time to first opioid use was 1.1 hours versus 0.7 hours in the multimodal analgesia and IV opioid PCA groups, respectively; P = 0.035. Two patients in the multimodal analgesia group and one in the IV opioid PCA group experienced opioid-related adverse events.ConclusionA liposome bupivacaine-based multimodal analgesic regimen reduced postoperative opioid consumption in patients undergoing ileostomy reversal under a fast-track discharge protocol. A reduction of 21% in LOS (0.8 days) was noted which, although not statistically significant, may be considered clinically meaningful given the already aggressive fast-track discharge program.

Re. Gillet al.: Management and short-term outcome of malignant colorectal polyps in the north of England

Colorectal DiseaseVolume 15, Issue 6 p. 763-764 Correspondence Re. Gill et al.: Management and short-term outcome of malignant colorectal polyps in the north of England S. Gonsalves, S. Gonsalves Department of Colorectal Surgery, Calderdale and Huddersfield NHS Trust, UKSearch for more papers by this authorS. Anwar, S. Anwar [email protected] Department of Colorectal Surgery, Calderdale and Huddersfield NHS Trust, UKSearch for more papers by this author S. Gonsalves, S. Gonsalves Department of Colorectal Surgery, Calderdale and Huddersfield NHS Trust, UKSearch for more papers by this authorS. Anwar, S. Anwar [email protected] Department of Colorectal Surgery, Calderdale and Huddersfield NHS Trust, UKSearch for more papers by this author First published: 09 April 2013 https://doi.org/10.1111/codi.12240Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume15, Issue6June 2013Pages 763-764 RelatedInformation

Appraisal of the LIFT and BIOLIFT procedure: initial experience and short-term outcomes of 33 consecutive patients

A new sphincter-saving technique known as the LIFT (ligation of intersphincteric tract) procedure has gained growing interest. Use of a bioprosthetic device has also been suggested to augment the LIFT procedure (BIOLIFT). This study evaluates outcomes of patients undergoing LIFT and BIOLIFT for repair of complex anal fistulae. This study is a single-surgeon, single-centre retrospective review of a prospectively collected database. Study was conducted at Royal Prince Alfred Hospital Department of Colorectal Surgery, Sydney, Australia, from May 2009 to April 2012. Thirty-three patients were evaluated. Twenty-nine LIFTs and five BIOLIFT procedures were evaluated. Primary success is defined as successful healing from initial procedure while secondary success is successful healing after management of failure or recurrence. In a cohort of predominantly female (67 %) and 94 % transsphincteric fistulae, primary success was 63 %. At a median follow-up of 20 weeks (6-81 weeks), there were 11 failures and one recurrence. The median time to failure/recurrence was 3 weeks (1-25 weeks). Six patients had a subsequent fistulotomy and three patients had a BIOLIFT for non-successful outcomes. The median follow-up for those with failures/recurrences is 60 weeks (range 20-76 weeks) and secondary success was 88 %. Post-operative anal manometry studies showed a 9 % reduction of resting and 11 % reduction of squeeze pressures but this was not statistically significant. There was also no post-operative incontinence. Anterior fistulas were noted do significantly worse (47%) compared with non-anteriorly located fistulas (84 %; p = 0.03). LIFT and BIOLIFT procedures can be performed safely and effectively in a technically demanding study cohort of predominantly females with complex fistulas. Anterior fistulas have a higher risk of failure but present early and are amendable to repeat procedures. In particular, fistulotomies are useful in downstaged tracts and performing BIOLIFTs is an alternative in the management of LIFT failures and recurrences.

Chronic Anal and Perianal Pain Resolved With MRI

The purpose of this study was to assess the diagnostic value of anorectal MRI in the care of patients with chronic anal and perianal pain but without findings of abnormalities in the clinical workup. Patients referred from a tertiary department of colorectal surgery to the MRI unit with clinically occult chronic anal and perianal pain were included. MRI of the anorectum was performed with an endoanal or pelvic phased-array coil. The images from all examinations were read by two radiologists. MRI findings were correlated with clinical follow-up data. The study group (103 patients) was stratified into patients with no history of anorectal disease (n = 60) and those who had a history of surgery for anorectal disease (n = 43). MRI findings suggested the final diagnoses in 40 patients (39%). These diagnoses were 28 cases of suppurative lesions (27%), 11 cases of painful scarring of the anus (11%), and one case of metastasis to the sacrum (1%). Suppurative lesions were surgically proved with marked relief of pain after surgery. In the other patients the final diagnoses were 37 cases of levator ani syndrome (36%) and 26 cases of unspecified functional anorectal pain (25%). No MRI abnormalities were found in 33 of the patients with levator ani syndrome and 26 of the patients with unspecified anorectal pain. The two readers had very good agreement (κ = 0.92). The patients with a history of anorectal disease had significantly more MRI findings of abnormalities (60%) than did patients without a history of anorectal disease (23%). The positive predictive value of MRI was 91%, and the negative predictive value was 100%. In 39% of patients, MRI showed abnormalities that were clinically confirmed as the final diagnosis. Surgical treatment will especially benefit patients with suppurative lesions, resulting in relief of pain.

The Road Map to Better Knowledge? Care Pathways as an Educational Tool During Surgical Internship

Changes in medical practice have promoted a culture of standardized care. Care pathways have been proven to raise the quality of clinical care. Their effect as an educational tool has not been evaluated to date. To examine the educational role of care pathways in elective surgical admissions during surgical internship and the effect of their introduction on interns' confidence in performing tasks. A questionnaire survey was filled in by interns to determine their confidence in performing different tasks during elective surgical admission and postoperative care. Care pathways were then formulated for the commonest procedures within the Department of Colorectal Surgery. The same interns then repeated the same questionnaire after they were exposed to the care pathways. Thirty interns participated in the study with a 100% response rate. There was statistically significant improvement in tasks performed confidently in 20 out of 21 areas surveyed after the introduction of the care pathways. The percentage of tasks performed with no confidence decreased from 25% to 1% (p<0.001). Care pathways are an effective method to improve the efficiency and confidence of interns in different aspects of surgical care, thereby improving patient safety. They also function as a valuable educational tool to aid interns in the management of patients with complex surgical issues.