Proctectomy In Patients Research Articles

Local excision vs. proctectomy in patients with ypT0–1 rectal cancer following neoadjuvant therapy: a propensity score matched analysis of the National Cancer Database

BackgroundWe aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer.MethodsThis retrospective observational study using the National Cancer Database (NCDB) included patients with locally advanced non-metastatic rectal cancer (ypT0–1 tumors) treated with neoadjuvant therapy between 2004 and 2019. Outcomes of patients who underwent LE or proctectomy were compared. 1:1 propensity score matching including patient demographics, clinical and therapeutic factors was used to minimize selection bias. Main outcome was overall survival (OS).Results11,256 of 318,548 patients were included, 526 (4.6%) of whom underwent LE. After matching, mean 5-year OS was similar between the groups (54.1 vs. 54.2 months; p = 0.881). Positive resection margins (1.2% vs. 0.6%; p = 0.45), pathologic T stage (p = 0.07), 30-day mortality (0.6% vs. 0.6%; p = 1), and 90-day mortality (1.5% vs. 1.2%; p = 0.75) were comparable between the groups. Length of stay (1 vs. 6 days; p < 0.001) and 30-day readmission rate (5.3% vs. 10.3%; p = 0.02) were lower in LE patients. Multivariate analysis of predictors of OS demonstrated male sex (HR 1.38, 95% CI 1.08–1.77; p = 0.009), higher Charlson score (HR 1.52, 95% CI 1.29–1.79; p < 0.001), poorly differentiated carcinoma (HR 1.61, 95% CI 1.08–2.39; p = 0.02), mucinous carcinoma (HR 3.53, 95% CI 1.72–7.24; p < 0.001), and pathological T1 (HR 1.45, 95% CI 1.14–1.84; p = 0.002) were independent predictors of increased mortality. LE did not correlate with worse OS (HR 0.91, 95% CI 0.42–1.97; p = 0.82).ConclusionOur findings show no overall significant survival difference between LE and total mesorectal excision, including ypT1 tumors. Moreover, patients with poorly differentiated or mucinous adenocarcinomas generally had poorer outcomes, regardless of surgical method.

P272 Healing of Perineal Wounds after Proctectomy for Crohn's Disease: A Systematic Review and Meta-Analysis

Abstract Background Non-healing perineal wounds are common in patients undergoing proctectomy for Crohn’s disease. We systematically reviewed the literature and performed a meta-analysis to estimate the pooled proportion of perineal wound healing after proctectomy for Crohn’s disease. Methods A comprehensive literature search was conducted in PubMed, Embase, and Scopus databases to identify relevant studies reporting perineal wound healing after proctectomy in patients with Crohn’s disease from 2010 to 2023. Articles were screened and those reporting perineal wound healing rates after proctectomy were included. Data on the study characteristics and proportion of healed wounds were extracted. Random effects meta-analysis was performed to estimate the pooled proportion and 95% confidence intervals using the ‘meta’ package in R. Heterogeneity was assessed using the I2 statistic. Results The literature search yielded 501 articles, of which 252 articles remained after removing duplicates. After screening the titles and abstracts, four retrospective cohort studies involving 332 patients with Crohn’s who underwent proctectomy were included in the meta-analysis. Across the four studies, the pooled proportion of completely healed perineal wounds at 6 months was 65% (95% CI 52%-80%) and at 12 months was 70% (95% CI 60%-83%). Significant heterogeneity was found between studies (I2=86% at 6 months). Only one study examined the predictors of impaired healing after proctectomy. Factors such as age, sex, BMI, smoking, steroid use, presence of high fistula-in-ano, and surgical technique were not significantly associated with impaired healing in univariate and multivariate analyses in this study. However, preoperative perineal sepsis was independently associated with impaired healing in the univariate and multivariate analyses in this study (p = 0.001). Study 4 included both Crohn's disease (n=54) and ulcerative colitis (n=20) patients who underwent proctectomy and reported fewer overall perineal complications in patients with UC than in those with Crohn’s disease (15% vs. 46.3%, p=0.01). Conclusion This meta-analysis revealed complete perineal healing in 70% of patients with Crohn's 12 months after proctectomy. Significant heterogeneity was observed between the studies. This review highlights the gaps in the best practices for optimizing perineal wound healing after proctectomy. These findings suggest the need to study techniques, such as vacuum-assisted closure and flap reconstruction. Further research is needed to identify modifiable factors to increase healing rates and develop evidence-based protocols for surgical approach, wound closure, and postoperative care in Crohn's disease patients.

Development of surgical concepts in rectal cancer resection and challenges in minimally invasive surgical proctectomy

Since the early 1900s there have been dramatic changes in the management of patients with rectal cancer. Surgical approaches initially performed for palliation, have now been adapted, modernised and undertaken as part of a multimodal approach. This has resulted in significant improvements in long-term oncological survival and patient quality of life. With the introduction of total mesorectal excision (TME) in the 1980's, and its global acceptance by the surgical community, local and distant disease-free survival in patients with rectal malignancy has significantly improved. Since the inception of minimally invasive surgery, laparoscopy has seen dramatic changes both in the evolution of technological advances and application in multiquadrant surgery for colorectal malignancy. Favorable short-term clinical benefits and long-term oncological equivalence from many multicentre randomized controlled trials in laparoscopic colonic cancer resection has led the colorectal surgical community to translate and adapt minimally invasive surgical (MIS) techniques for proctectomy in patients with rectal tumours. MIS proctectomy is technically challenging and is associated with a steep learning curve. Reported challenges in the literature continuously identify a group within three common themes which can be divided into patient/anatomical factors, tumour characteristics and the use of neoadjuvant therapies. Despite a large body of evidence highlighting efficacy of MIS in proctectomy, significant challenges exist in male patients with a narrow pelvis and distal tumors. Such patients are at increased risk of a poor surgical specimen, positive distal and circumferential resection margins (CRMs), and increased local recurrence. Despite advances in laparoscopy and robotic platforms, approaching such lesions from a “top down” approach expose the ongoing limitations to lower pelvic access. This technically challenging issue has led to the colorectal surgical community adopting previously taught MIS techniques to develop a “bottom up” transanal approach to TME, now known as transanal TME (taTME) in order to mitigate this increased margin risk.

Risk factors for proctectomy in consecutive Crohn\u2019s colitis surgical patients in a reference colorectal centre

PurposeCrohn’s colitis carries a risk for permanent stoma with extirpation of the rectum. We aimed to estimate the proctectomy rate and identify risk factors for proctectomy in patients with Crohn’s colitis.MethodsFor this study, we retrospectively reviewed data from consecutive patients with Crohn’s disease (CD) affecting the colon or anorectal region undergoing bowel resection in a reference colorectal centre between 2006 and 2016. The cumulative risk for proctectomy was calculated using the Kaplan-Meier curve. We used univariate and multivariate logistic regression analyses to determine independent risk factors for proctectomy. Outcomes after proctectomy concerning reoperation frequency and perineal wound healing are also described.ResultsIn total, this study included 125 patients. Proctectomy was performed in 36 patients (28.8%), of whom 14 patients (38.9%) experienced perineal wound healing problems. The rates of proctectomy were 5.6% and 32.0% 10 and 20 years after CD diagnosis, respectively. Female gender (odds ratio (OR) 3.375, 95% confidence interval (CI) 1.304–8.733, P = 0.012), disease duration (OR 1.067, 95% CI 1.011–1.126, P = 0.018) and history of perianal disease (OR 3.160, 95% CI 1.215–8.219, P = 0.018) were independent risk factors for a proctectomy procedure, whereas thiopurine medication (OR 0.170, 95% CI 0.060–0.486, P = 0.001) was an independent protective factor for proctectomy.ConclusionsThe duration of Crohn’s disease, female gender and a history of perianal disease were significant risk factors for a proctectomy procedure. Future research should examine whether immunosuppressive and biological medications reduce the risk for proctectomy.

Previous radiation for prostate neoplasm alters surgical and oncologic outcomes after rectal cancer surgery

Previous radiation for prostate cancer (PC) contra-indicates neoadjuvant chemoradiotherapy for rectal cancer (RC) because of risk of cumulative radiation dose toxicity. Postoperative outcomes after proctectomy have not been well studied in these patients who did not receive optimal treatment. Eighty-four consecutive male patients underwent surgery for stage II-III mid or low RC between 2002 and 2011. Patients who previously received radiation for PC (n = 8) and patients who had not previously undergone radiation for PC but who received neoadjuvant chemoradiotherapy for RC (n = 64) were retrospectively compared. Previous radiation for PC was an independent factor that significantly increased intraoperative (25% vs. 1.6%, P = 0.002) and postoperative morbidities (62.5% vs. 28.1%, P = 0.028), anastomotic leakage (62.5% vs. 12.5%, P < 0.001) and definitive stoma rates (25% vs. 17.4%, P = 0.022). It significantly altered median overall survival (32.0 vs. 130.6 months, P = 0.05) and local recurrence-free survival rates (14.0 months vs. "median not reached," P = 0.016). This is the first report of altered survival rates after proctectomy in patients who had previously received radiation for PC. Postoperative morbidity and definitive defunctioning stoma rates were significantly increased in these patients with poor prognoses. Therapeutic strategies should thus be individualized. Large, multicenter cohort studies are needed.

Clinical Complete Response After Neoadjuvant Therapy in Rectal Cancer: Is Surgery Needed?

Neoadjuvant chemoradiation followed by proctectomy is the recommended treatment plan for locally advanced rectal cancer in the USA. After chemoradiation, approximately 20 % of patients experience a complete pathologic response, which is associated with improved oncological outcomes. This observation prompted questions about the necessity of surgery if the tumor has completely regressed. Using clinical complete response as a surrogate for pathologic response, the watch and wait approach was introduced as an attempt at organ preservation utilizing active surveillance protocols rather than surgery. Prospective studies have highlighted the potential benefits of this approach, with successful organ preservation and comparable oncologic outcomes. Non-operative protocols are based on thorough response assessment using clinical exam, imaging, and laboratory tests with frequent repeat examinations to detect residual or recurrent disease in a timely manner. Although a subset of patients benefit from this approach, accurate identification of appropriate patients remains challenging. Debate continues regarding use of non-operative surveillance or standard proctectomy in patients deemed to have a complete clinical response. This review discusses the current data as well as the challenges of this approach.

Desmoid Tumors Do Not Prevent Proctectomy Following Abdominal Colectomy and Ileorectal Anastomosis in Patients With Familial Adenomatous Polyposis

Elective proctocolectomy has been recommended for patients at high risk of desmoids based on the possibility that cancer in a retained rectum may be unresectable because of desmoid disease. There are no data to support the reality of this concern. The aim of this study was to see how often proctectomy was prevented by desmoids. This retrospective, descriptive, database study was augmented by chart review. This study was conducted at a hereditary colorectal cancer clinic in a tertiary referral center. Those presenting for proctectomy after colectomy and ileorectal anastomosis for familial adenomatous polyposis were selected. Patients underwent a proctectomy. The primary outcomes measured were the rate of proctectomy, rate of IPAA, and the incidence of desmoid disease. Sixty- seven patients, 34 men and 33 women, underwent an operation with the intent of performing proctectomy. Mean age at surgery was 39.7 years, an average of 175 months from ileorectal anastomosis. Indications for proctectomy were uncontrollable adenomas in 56, cancer in 8, and high-grade dysplasia in 3. Proctectomy was always possible. Ileal pouch-anal anastomosis was planned in 62 patients; 54 had this operation. Desmoid disease was found in 26 patients (38.8%) and influenced surgery in 13 cases, stopping pouch-anal anastomosis in 8. One patient had no resection, 2 had a pouch-low rectal anastomosis, and 5 had proctectomy and ileostomy. Proctectomy and ileostomy was planned in 5 patients and performed in all. This is a retrospective review from a single institution. The fear of an unresectable rectum or an impossible pouch-anal anastomosis should not be an indication for proctectomy in patients with low rectal polyp counts but a high risk for desmoid disease.

The American Society of Colon and Rectal Surgeons 2013 annual meeting

The 2013 Annual Scientific Meeting of the American Society of Colon and Rectal Surgeons (ASCRS) took place in Phoenix, Arizona, from April 27th to May 1st. Visitors could enjoy many cultural and natural attraction in the area, such as the Sonoran Desert, the Frank Lloyd-Wright house museum, and the spectacular Grand Canyon. The meeting was attended by more than one thousand general surgeons and colorectal specialists. The scientific sessions included symposia assessing state-of-the-art on diagnosis and treatment modalities, lectures to honor surgeons who have made important contributions to the field of colorectal surgery, such as V. Fazio, N. Nigro, and E. Hambrick, hands-on workshops, and an ongoing video display. There were 374 posters and 80 podium presentations. A webcast including the presentations in the 2 main halls will be provided online shortly after the meeting. The scientific program focused on the main and most frequent disorders affecting the colon, rectum, and anus with the purpose of improving patient care. In the ‘‘Core subject update’’ session, the evidencebased reviews of current diagnosis, treatment, controversies, and pitfalls of 24 topics, in a rotating 4-year cycle, are presented every year and discussed with the audience. The topics this year included colon cancer, diverticulitis, different types of colitis, fecal incontinence, fistula and abscess, and perioperative management. For those interested, a summary of each topic is available on the ASCRS website. Optimal treatment of colon and rectal cancer continues to evolve, and despite the central role of surgery, a multidisciplinary approach is nowadays essential. Surgeons should therefore have a throughout comprehension of the role and timing of different treatments. The proper surgical TME technique and methods of reconstruction after restorative proctectomy in patients with rectal cancer were discussed. Unfortunately, 2 techniques that are now becoming popular in Europe, namely intersphincteric resection and the anterior perineal planE for anterior resection of the rectum (APPEAR) technique, were not taken into consideration. An excellent lecture on low anterior resection syndrome was given by the present president of the European Society of Coloproctology, S Lauberg. In the presentations on colon cancer, the significance of high or low vessel ligation and excision of the mesocolon were discussed. Laparoscopy is gaining more and more acceptance all over the world, because of patients’ request for less invasive surgery, the development of new technology, and surgeons’ improving skills. However, in the USA, only an estimated 40 % of surgeons have adopted minimally invasive techniques for colon cancer and even less perform minimally invasive surgery for rectal cancer. In this field, technological advances and surgical strategies, including single-port surgery, robotic dissection, natural orifice transluminal endoscopic surgery (NOTES), and transanal minimally invasive surgery (TAMIS), were demonstrated by highvolume surgeons, including C Delaney, T Young-Fadok, and A Fichera. A 2-h session assessing the outcomes of these techniques was also presented in order to provide information leading to better surgical decision-making. Inflammatory bowel disorders are rarely primarily managed by surgeons who, in some instances, may lack experience in medical treatment. Indications, complications, and P. De Nardi (&) A. Vignali Department of Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy e-mail: denardi.paola@hsr.it

Transanal Endoscopic Surgical Proctectomy for Proctitis Case Series Report: Diversion, Radiation, Ulcerative Colitis, and Crohn’s Disease

Background: With recent trends in natural orifice surgery, there has been a rising interest in the evolution of transanal endoscopic surgery (TES) and transanal access platforms. Transanal endoluminal removal of rectal masses has matured into transanal endoscopic surgical resection of the rectum for benign and malignant disease. The purpose of this study is to evaluate the surgical outcomes of TES completion proctectomy in patients with proctitis in a retained rectum. Methods: This is a retrospective case series report. Patient demographics and peri-operative outcome variables were recorded. Results: TES proctectomy was successfully performed in 6 patients using a disposable transanal access platform. The patient’s ages ranged from 22 – 74 years, 4 women and 2 men, BMI ranged from 22 – 51 kg/m2. The indication for surgery was proctitis in a retained rectum: diversion (n=1), radiation (n=1), ulcerative colitis (n=2), and Crohn’s disease (n=2). Four applications of TES proctectomy were employed: TES completion proctectomy (n=2), TES assisted single incision abdominal perineal resection (n=1), TES assisted laparoscopic restorative proctectomy with colo-anal anastomosis (n=1), and TES assisted laparoscopic restorative total proctocolectomy with ileal pouch anal anastomosis (n=1). The operative time for TES completion proctectomy ranged from 140 – 238 minutes (n=4). The operative time for TES restorative proctectomy was longer at 446 min and 557 min (n=2). The hospital length of stay for both TES completion and restorative proctectomy ranged from 2 – 5 days (n=5). Complications included 1 urinary tract infection, 1 chronic draining perineal sinus tract, and 1 perineal wound dehiscence requiring re-operation. All six patients are doing well at the time of follow up (range 3 – 19 months). Conclusions: TES completion proctectomy alone or in combination with laparoscopic abdominal surgery is a safe and effective method to perform proctectomy and restorative proctectomy in this small case series of patients with proctitis in a retained rectum due to diversion, radiation, ulcerative colitis, and Crohn’s disease. Keywords: TES, TAMIS, Completion Proctectomy, Ulcerative Colitis, Proctitis, Regional Proctitis, Crohn’s Disease, Radiation Proctitis, Natural Orifice Surgery, Transanal Endoscopic Surgery. Read more →

Fate of the Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis is considered the procedure of choice for patients requiring elective surgery for ulcerative colitis, but some patients undergoing subtotal colectomy with end ileostomy are satisfied with an ileostomy and do not choose to undergo later pelvic pouch surgery. The need and timing for completion proctectomy in this setting are uncertain. To assess the long-term fate of the retained rectum compared with the morbidity associated with completion proctectomy in patients who underwent subtotal colectomy for ulcerative colitis. Retrospective review of a prospective database in an academic medical center. Patients who underwent subtotal colectomy with ileostomy for ulcerative colitis from July 1, 1990, to December 31, 2010. Proctectomy, surgical complications, and symptoms from the retained rectum. One hundred eight patients underwent subtotal colectomy for ulcerative colitis during the study period: 73 for acute disease, 18 for advanced age and/or comorbidities, and 17 to avoid the risk of sexual dysfunction or infertility. Of these patients, 71 (65.7%) underwent subsequent ileal pouch-anal anastomosis, 2 died of other causes, and 3 were lost to follow-up. Of the remaining 32 patients, 20 chose rectal stump surveillance and 12 underwent elective proctectomy. Median follow-up was 13.8 years. No difference was noted in age, sex, surgical complications, pad use, or urinary dysfunction between the 2 groups. Only 8 of 20 patients in the surveillance group were compliant with follow-up endoscopy, and 13 were able to maintain their rectum; 2 required proctectomy at 11 and 16 years, respectively, for rectal cancer; neither has developed recurrent disease. One patient in each group reported erectile dysfunction. Management of the retained rectum after subtotal colectomy remains an important issue even in the era of ileal pouch-anal anastomosis. Considering the risk of rectal cancer, the low success rate of long-term rectal preservation, and the safety of surgery, a more aggressive approach to early completion proctectomy seems justified in this situation.

Transanal Endoscopic Proctectomy

In rectal surgery, some situations can be critical, such as anterior topography of locally advanced low tumors with a positive predictive radial margin, especially in a narrow pelvis of men who are obese. Transanal proctectomy is a new laparoscopic technique that uses the transanal endoscopic microsurgery device. The aim of this study is to evaluate the technical feasibility of laparoscopic transanal proctectomy in patients with unfavorable features. This is a single-center, prospective analysis of selected patients with rectal cancer operated on from January 2009 to June 2011. Intraoperative details and short-term postoperative outcome were described. Thirty men with advanced or recurrent low rectal tumors associated with unfavorable anatomical and/or tumor characteristics underwent a sphincter-sparing transanal endoscopic proctectomy. Twenty-nine patients had received preoperative treatment. We report a 6% conversion rate, no postoperative mortality, and a 30% morbidity rate. At the beginning of our experience, a urethral injury was diagnosed in 2 patients and easily sutured intraoperatively, without postoperative after-effect. The mesorectal resection was graded as "good" in all patients. R0 resection was achieved in 26 patients (87%). The short-term stoma closure rate was 85%. After a median follow-up of 21 months, 4 patients experienced locoregional recurrence alone. Overall survival rates at 12 and 24 months were 96.6% (95% CI, 78.0-99.5) and 80.5% (95% CI, 53.0-92.9). Relapse-free survival rates at 12 and 24 months were 93.3% (95% CI, 75.9-98.3) and 88.9% (95% CI, 69.0-96.3). Although the transanal endoscopic proctectomy was performed by trained surgeons, we report a slight increase in early postoperative morbidity and relatively poor early outcome. There was a clear selection bias related to the study cohort exclusively composed of high-risk patients, but we need to be cautious before generalizing this technique. The transanal endoscopic proctectomy is a feasible alternative surgical option to conventional laparoscopy for radical rectal resection in selected cases with unfavorable characteristics. Further investigations with larger cohorts are required to validate its safety and to clarify its best indication.

Robotic‐assisted laparoscopic stage II restorative proctectomy for toxic ulcerative colitis

There is a paucity of literature reporting minimally invasive proctectomy for ulcerative colitis (UC). We report a novel application of a robotic system to perform restorative proctectomy in patients with toxic UC. Retrospective review, case series report. Robotic-assisted laparoscopic proctectomy with ileal J-pouch anal anastomosis was performed in three patients with toxic UC. All patients previously underwent urgent laparoscopic total abdominal colectomy. One female and two male patients were aged 39, 24 and 43, respectively. The procedures were performed safely with minimal complications. The robotic proctectomy operative time was reduced from 134 to 106 min. None of the patients have experienced fecal incontinence, nocturnal seepage or sexual dysfunction. This is a case series report of a robotic-assisted laparoscopic proctectomy with restorative ileal J-pouch in patients with toxic UC. This technique has been previously described for use in patients with medically refractory UC and neoplasia associated with chronic UC. This series exemplifies an ideal application of a robotic system with improved visibility, rotation and ergonomics.

Robotic-Assisted Proctectomy for Inflammatory Bowel Disease: A Case-Matched Comparison of Laparoscopic and Robotic Technique

BackgroundThe objective of this study was to compare short-term outcomes of robotic and laparoscopic proctectomy in patients with inflammatory bowel disease (IBD). MethodsThis is an IRB-approved case-matched review. Seventeen robotic proctectomies (RP), 10 with ileal pouch anal anastomosis (IPAA) and 7 completion (CP), were matched to laparoscopic proctectomies (LP). Short-term and functional outcomes were compared between LP and RP. ResultsIn CP cohort, operative times were longer in the RP group (351 RP vs 238 LP min, p = 0.03), mean robotic time 90 min. Estimated blood loss (EBL) was similar between RP-CP and LP-CP groups (p = 0.18). Return of bowel function (RBF) was slower in RP-CP group (3.0 vs 1.7 days, p = 0.04), and length of stay (LOS) was longer (6.4 vs 4.1 days, p = 0.02). In the IPAA group, there were no differences between operative times (p = 0.14), robotic time 86 min; EBL (p = 0.15), and postoperative complications. Return of bowel function (3.6 vs 2.6 days, p = 0.3) and LOS (8.5 vs 6.1 days, p = 0.17) were similar between RP and LP. Bowel and sexual function were equivalent between LP and RP-IPAA groups. ConclusionsRobotic proctectomy is a safe and effective technique for patients with IBD. It is comparable to LP with regard to perioperative outcomes, complications, and short-term functional results.

Risk factors for secondary proctectomy in patients with familial adenomatous polyposis

Colectomy and ileorectal anastomosis (IRA) or restorative proctocolectomy are performed for prophylaxis in familial adenomatous polyposis (FAP). After IRA patients may require secondary proctectomy for worsening polyposis or rectal cancer. Outcomes after IRA were evaluated and risk factors predictive of progressive rectal disease identified. Parametric survival analysis was used to identify predictors of progressive rectal disease in all patients undergoing an IRA for FAP at a single centre. Hazard ratios (HRs) were calculated for phenotype, genotype, sex, age at surgery and presence of colonic cancer. Of 427 patients who underwent IRA, 48 (11.2 per cent) developed rectal cancer and 77 (18.0 per cent) required proctectomy for worsening polyposis over a median follow-up of 15 (range 7-25) years. By the age of 60 years half of the patients retained their rectum. Rectal polyp count exceeding 20 (HR 30.99, 95 per cent confidence interval 9.57 to 100.32; P < 0.001), APC mutation codon 1250-1450 (HR 3.91, 1.45 to 10.51; P = 0.007), colonic polyp count 500 or more (HR 2.18, 1.24 to 3.82; P = 0.006) and age less than 25 years at the time of surgery (HR 1.99, 1.17 to 3.37; P = 0.011) were independent predictors of progressive rectal disease. The risk of proctectomy after IRA for FAP is based on patient genotype, phenotype and age at surgery.

Untreatable faecal incontinence: colostomy or colostomy and proctectomy?

PURPOSE: To determine the frequency of rectal symptoms and secondary proctectomy in patients undergoing elective permanent end sigmoid colostomy for faecal incontinence and determine risk factors. METHODS: A retrospective chart review of patients undergoing elective end sigmoid colostomy for faecal incontinence at St Mark's Hospital between January 1991 and December 1998. Patients were divided into three groups: A, symptoms leading to subsequent proctectomy; B, symptomatic but avoiding proctectomy; C, asymptomatic. RESULTS: There were 44 patients (80% women, average age 57 years): Group A 12 (27%); Group B 13 (30%); Group C 19 (43%). Group A were on average younger than Group C (45 years vs 64 years, P < 0.05). No other risk factor for symptoms or proctectomy was evident, and in particular a prior history of obstructed defaecation/anal digitation was not related. Only half the patients undergoing proctectomy had histological evidence of defunctioned proctitis in the resected rectum. CONCLUSIONS: Data are insufficient presently to recommend primary proctectomy in this group of patients (even if it were to be performed laparoscopically).

Ultrasonic Mucosal Proctectomy in Patients with Ulcerative Colitis

A technique for performing mucosal proctectomy in patients with ulcerative colitis using ultrasonic fragmentation is described. Twenty-eight patients undergoing colectomy and ileoanal anastomosis were studied. Removal of the mucosal layer of the distal rectum was performed using a titanium probe vibrating at 23 kHZ with an amplitude of 300 microns. This method produces complete mucosal destruction and the resulting debris and irrigating fluid is removed through the hollow central portion of the probe. Healing of the ileoanal anastomosis does not appear to be adversely affected by the use of this technique. Because ultrasonic fragmentation is not dependent on the integrity of the submucosal plane, it may be advantageous in those cases in which severe inflammation and submucosal scarring make manual dissection of the rectal mucosa difficult to perform.