Rectal Washout Research Articles

Rectal washout and local recurrence of cancer after anterior resection

Adenocarcinomas of the rectum shed viable cells, which have the ability to implant. Intraoperative rectal washout decreases the amount and viability of these cells, but there is no conclusive evidence of the effect of rectal washout on local recurrence after rectal cancer surgery. Data were analysed from a population-based registry of patients who had anterior resection from 1995 to 2002 and were followed for 5 years. Rectal washout was performed at the discretion of the surgeon. National inclusion of patients with rectal cancer and follow-up was near complete (approximately 97 and 98 per cent respectively). A total of 4677 patients were analysed (3749 who had washout, 851 no washout and 77 with information missing); 52.0 per cent of patients in the washout group and 41.4 per cent in the no-washout group had preoperative radiotherapy (P < 0.001). Local recurrence rates were 6.0 and 10.2 per cent respectively (P < 0.001). Univariable and multivariable logistic regression analyses produced odds ratios that favoured washout: 0.56 (95 per cent confidence interval (c.i.) 0.43 to 0.72) and 0.61 (0.46 to 0.80) respectively (both P < 0.001). In multivariable analysis restricted to patients who had curative surgery, the odds ratio was 0.59 (95 per cent c.i. 0.44 to 0.78; P < 0.001). There was a more favourable outcome in patients after rectal washout than without.

What is the most common complication after one-stage transanal pull-through in infants with Hirschsprung’s disease?

Hirschsprung's disease (HD) is a relatively common congenital disease that could be suspected by clinical symptoms, abdominal plain X-ray, and finally diagnosed by rectal biopsy. In 80% cases, rectosigmoid junction is involved. Recently, one-stage transanal pull-through (TAPT) procedure has been popular and may have several complications. During a 4-year period, 86 infants (28 girls, 58 boys) with mean age 8 days (3-33) and clinically suspected to HD were admitted in our center. HD was proved by rectal biopsy. All patients after full bowel preparation and rectal washout were candidates for TAPT operation. A Swenson-like procedure was performed and the anastomosis was done between the well blood supply ganglionic colon and the rectum at 1 cm above dentate line. Interrupted suture with 5-0 Vicryl was used. Nelaton tube (12 F) inserted in the pelvis via transprineal for drainage of blood or collection. From February 2008 in 30 cases, prophylactic Hegar dilatation was performed 2 weeks after operation. Anal stricture in 12 cases (14%) was treated by anal dilation in 10 cases and 2 cases corrected by surgical management. Entrocolitis in 4 cases (5%) was treated by medical management. In two cases, retrocolic abscess had spontaneous drainage via tube drain. There was no anastomotic stricture after starting prophylactic anal bouginage. TAPT has many advantages, low complications and the results are excellent. It seems the most common complication is anastomotic stricture that responds well to prophylactic bouginage. We recommend prophylactic anal bouginage with Hegar probe at 2 weeks after operation. Long-term follow-up is needed to evaluate the outcomes of our operations.

Prospective surgico-pathologic registration study of colorectal cancer (Swiss Group for Clinical Cancer Research SAKK protocol 40/00): Current practices and short-term outcome.

e14053 Background: The short term aim of this study was to estimate the radicality of colorectal cancer resections and to assess the oncosurgical quality of the colorectal specimens. Methods: One German and 9 Swiss hospitals agreed to prospectively register all patients with primary colorectal cancer resected between September 2001 and June 2005. Out of 1,502 consecutive patients, informed consent was obtained from 1,010 patients for further analyses. The median number of included patients per center was 99 (13-219). Results: The median age at operation was 70.3 years, the mean ASA score was 2.2. Tumor disease: synchronous second primary 3.6%; emergency operation 6.4%; multivisceral resections 10%, 92.2% out of these as en-bloc resection; node positive patients 39.4%; UICC stage IV patients 17.7%. Radicality: local R2-resection 3.6%; median length of bowel specimen 26cm; median distances from tumor to nearest bowel resection margin 7 cm for colon cancer and 2.5 cm for rectal cancer; maximum length of mesocolon median 9 cm; median number of examined lymph nodes 16. Oncosurgical quality: no-touch technique 49.5%; tumor opened during dissection 4.6%; median blood loss 300 mL; death during hospital stay 2.6%; anastomotic leakage 4.5%; intraabdominal abscess 5%. Rectal cancer only (n = 412): local excision only 10.7%; mesorectal excision 95.2% of abdominal approaches; rectal stump washout 64.6%; stoma formation 79.8%; involvement of circumferential resection margin 8.9%. Calculating the medians of each center separately, the following variations of medians were found: length of bowel specimen 20–40 cm, maximum length of mesocolon 6.5–12cm, number of examined lymph nodes 9-24, blood loss 200–500 mL, percentage of abdominoperineal resection for rectal cancer 6%–30%. Conclusions: The presented results of colorectal cancer surgery are good to excellent with regard to radicality, oncosurgical quality and morbidity/mortality. Although all participating centers are at a high level of expertise in colorectal surgery and with special interest in surgical oncology, the results still show a potential for improvement in surgical technique in some. No significant financial relationships to disclose.

Risk factors of rectal cancer local recurrence: population‐based survey and validation of the Swedish rectal cancer registry

Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Local recurrence and survival rates of 4153 patients registered 1995-1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I-III, LR developed in 10% of tumours at 0-5 cm, 8% at 6-10 cm and 6% at 11-15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0-5 cm: OR 0.50 (0.30-0.83), 6-10 cm: OR 0.42 (0.25-0.71), and 11-15 cm: OR 0.29 (0.13-0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48-4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43-1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.

Laparoscopic Low Anterior Resection with Distal Rectal Washout Using the New Device of Gut-clamper

Background: Intraoperative rectal washout is considered to be importantin colorectal surgery, but it is rather difficult in laparoscopic surgery.To resolve the problem, a new device called gut-clamper have inventedfor complete washout of the rectum during the laparoscopic lowanterior resection.Methods: Forty patients with rectal cancer underwent laparoscopiclow anterior resection by a single skilled operator.Results: Thirty patients with rectal cancer underwent laparoscopiclow anterior resection with colorectal washout using gut-clamper. Therewas one complication of leakage in ten cases underwent without usinggut-clamper. The number of times using laparoscopic staplers was1.9�1.0 in the cases using gut-clamper, while that was 3.4 � 1.1 in thecases without using gut-clamper.Conclusion: This device of gut-clamper is easy and safe as well asreasonable physically and economically for intra-operative rectalwashout including laparoscopic colorectal resection.

The Occlusive Tourniquet: A Simple Method for Rectal Stump Washout During Open and Laparoscopic Surgery

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor to form an occlusive tourniquet. Occlusive tourniquet applied to laparoscopic technique: similar to the open technique, tubing is passed through the left iliac fossa trocar and passed behind the sigmoid mesocolon. This simple procedure allows easy exposure and dissection of the mesorectum, without traumatizing the rectum/sigmoid colon or the tumor and lavage can be performed without the need for clamps or other instruments which may traumatize the rectum and provoke anastomotic failure. In conclusion, the occlusive tourniquet is a simple method for rectal stump washout so this step can be done.

V6 The feasibility of laparoscopic rectal resection for cancer

Introduction: Total mesorectal excision (TME) has offered the lowest recurrence rates and best survival in rectal cancer patients. Recently several multi‐centre trials have demonstrated the feasibility of laparoscopic colonic resections for cancer. However the technical difficulties and lack of supporting data has prevented surgeons from attempting laparoscopic TME for operable rectal cancer. We present a video demonstration of lap TME technique performed at our unit for rectal cancer resections.Methods: The surgical technique involves using two 10 mm and two 5 mm ports to perform rectal resections. Adherence to advanced oncological principles like high tie of IMA and IMV is the rule. Splenic flexure is routinely mobilised for mid to low rectal cancers. Total mesorectal excision is performed using diathermy hook. Rectal washout is performed before transection of the rectum using lap stapler device.Results: Between October 2006–December 2007, 30 rectal cancers have been operated laparoscopically at our institution using this technique. There were four APER and 26 anterior resections. The median age was 72 years with a median BMI of 25. Median operative time was 235 min with a median hospital stay of 7 days. There were no leaks.Conclusions: With proper training and experience, laparoscopic rectal cancer resection is technically feasible and safe to perform with good oncological outcomes.

Is Rectal Washout Effective for Preventing Localized Recurrence After Anterior Resection for Rectal Cancer?

The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer. A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed. Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2-2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37-3.92). Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue.

Botulinium toxin, as bridge to transanal pullthrough in neonate with Hirschsprungs disease

Aims and Objectives:The aim of this study is to find easier way of home care while obviating the colostomy before single stage pull through operation.Materials and Methods:From August 2005 to December 2006, eight cases of neonatal Hirschsprung disease were treated. Mean age 4.5 (2-6) day/old with absent anorectal inhibitory reflex, rectosigmiod disease in Barium enema, positive Acetylcholine esterase (Ache) staining, good response to rectal washout. They underwent botulinium toxin injection (5 unit /kg/quadrant) in four quadrant intrasphincteric. They were followed until pull through operation in 8-10 weeks post injection.Results:Four of 8 (50%) cases only needed rectal washout for three to five days post injection until pull through operation, two had decrease in number of rectal washouts /day and the remaining two underwent colostomy five days post injection because of no response.Conclusion:Botulinium toxin injection can help in palliative care in patients with Hirschsprung disease who are waiting for colostomy or definitive pullthrough. It gives an option of eaiser home care for these patients.

Civilian Extraperitoneal Rectal Gunshot Wounds: Surgical Management Made Simpler

Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.

Long-term results show triple stapling facilitates safe low colorectal and coloanal anastomosis and is associated with low rates of local recurrence after anterior resection for rectal cancer

During low anterior resection (AR), placement of a staple line distal to an occlusion clamp is often difficult due to the confines of a narrow bony pelvis. This study reviewed the results of AR with a technique in which a linear staple line is fired below the tumour as an oncologically safe occlusion clamp. Between 1995 and 2000, a total of 174 patients were operated for rectal cancer, and 153 of these patients had AR. Triple stapling (TS) was used to place a line of staples that occluded the fully mobilised rectum below a tumour. After rectal washout, a further linear stapler was applied below the first, and the rectum was divided prior to a standard circular stapled anastomosis. TS was performed in 127 (83%) of 153 patients undergoing AR, and 9 TS patients developed leaks (7%). In the whole series of 174 cases, 9 patients had local recurrence (5%), but the local recurrence rate for procedures classified as 'locally curative' was 2%. Triple stapling reliably occludes the rectum allowing for distal rectal washout. It eliminates clamp slippage and faecal spillage and improves access to the distal rectum for low anastomoses.

Is Rectal Washout Necessary in Anterior Resection for Rectal Cancer? A Prospective Clinical Study

Implantation of exfoliated malignant cells has been suggested as a possible mechanism of tumor recurrence in colorectal anastomoses that might be prevented by cytocidal washout. The aim of our study was to assess whether malignant cells are likely to be collected by a circular stapler introduced transanally to perform an anastomosis and to observe local recurrences during follow-up, with special attention to the washout status of patients. Between May 1999 and March 2004, 96 patients with carcinoma of the rectum and distal sigmoid colon undergoing anterior resection under the care of three surgeons (only one of whom routinely performed rectal washout) were prospectively studied. While 38 patients had rectal washout with 5% povidone-iodine before anastomosis, 58 patients did not. A circular stapler was used for anastomosis, and the stapler was immediately rinsed in 100 ml of saline. The fluid was then classified as "acellular," "malignant cells identified," or "benign cells identified" by pathologists. Malignant cells were collected from the circular stapler after use in 3 patients (8%) on whom rectal washout was performed and in 2 (3%) patients who did not have rectal washout performed (P=0.631). Three patients (8%) in the washout group developed local recurrence, and 2 patients (3.4%) in the no-washout group had local recurrence (one was anastomotic recurrence) (P=0.338). The median follow-up time was 23 (range: 9-70) months. There were no differences in terms of the number of patients who had malignant cells collected from the circular stapler and local recurrence rates between the two groups. Although this is not a randomized study and size and mean follow-up time of the study were not sufficient, our results did not offer rational arguments in support of intraoperative rectal washout when a circular stapler is used after low anterior resection for carcinoma. Because of the limitations of our study, however, we are unable to arrive at a definite conclusion regarding rectal washout. There is a need for a randomized, controlled, large-scale, multicenter trial to establish the clinical relevance of intraoperative rectal washout.

Management of Civilian Extraperitoneal Rectal Injuries

The mortality and morbidity of rectal injuries are highly unsatisfactory. We retrospectively reviewed our experience with rectal injuries to draw some practical guidelines for management of such injuries. The medical records of all patients diagnosed at our hospitals with full-thickness rectal injuries between 1994 and 2003 were retrospectively reviewed. Full-thickness rectal injuries were identified in 23 patients; 19 patients had extraperitoneal injuries and four had both intra- and extraperitoneal injuries. The mean age was 33.5 years (range, 5-73 years). The mechanism of injury was penetrating in 11 patients, blunt in six, impalement in three and iatrogenic in three. Injuries were closed primarily in 17 patients, with variable combinations of adjunct procedures. Eight patients were treated without colostomy. Drainage and rectal washout were performed in 11 and six patients, respectively. Overall, 11 patients developed complications, including eight wound infections and five pelvic septic complications related to the rectal injury. Four of the five pelvic septic complications and all three deaths occurred in patients with shock, at least two associated-organ injuries and more than 6 hours' delay in treatment. Rectal injuries are serious additive mortality and morbidity factors in multi-injured patients. Regardless of treatment modality, wound infection is associated with shock at presentation and more than 6 hours' delay in treatment.

A physiological appraisal of polyethylene glycol and a balanced electrolyte solution as bowel preparation

Seventy-seven patients undergoing bowel preparation with either sennosides and rectal washout (S + RWO; n = 26) or polyethylene glycol and a balanced electrolyte solution (PEG + E) given orally (n = 25) or by nasogastric infusion (n = 26) have been studied. PEG + E was not associated with significant physiological change in electrolytes or blood gases. Patients tolerated PEG + E well and it provided a moderate to good bowel preparation in over 80 per cent of cases. PEG + E was not associated with a change in colonic microflora and was not associated with explosive mixtures of colonic gas due to hydrogen. It is therefore a safe, quick and efficient bowel preparation and provides a safer alternative to mannitol. The solution (PEG + E) man be used orally or by nasogastric infusion and does not require an accompanying intravenous infusion.

A case of infant botulism with a possible link to infant formula milk powder: evidence for the presence of more than one strain of Clostridium botulinum in clinical specimens and food

Infant botulism was confirmed in a 5-month-old female by both isolation of Clostridium botulinum type B and by detection of type B botulinum neurotoxin in rectal washout and faeces. DNA fingerprinting of nine isolates from faeces yielded two different amplified-fragment length polymorphism (AFLP) patterns. C. botulinum was isolated from two of 14 food and drink items from the patient's home: C. botulinum type A was recovered from an opened container of dried rice pudding and C. botulinum type B from opened infant formula milk powder. Ten C. botulinum type B isolates from the opened infant formula yielded four AFLP patterns, two of which were indistinguishable from the clinical isolates. Fifteen unopened foods were tested and C. botulinum type B of a unique AFLP pattern was recovered from one unopened infant formula of the same batch as the opened container. It is suggested that multiple C. botulinum were present in both food and the intestine during infant botulism.

Laparoscopy-Assisted Low Anterior Resection with a Prolapsing Technique for Low Rectal Cancer

Laparoscopy-assisted low anterior resection (LAR) for low rectal cancer is a difficult procedure, presenting problems with rectal washout, selecting the appropriate distal transection line, and achieving safe anastomosis. To resolve these problems, we used a prolapsing technique to perform laparoscopy-assisted LAR. Total mesorectal excision (TME) is performed laparoscopically. The proximal colon is transected laparoscopically with the aid of an endoscopic stapler, and the distal rectum, including the lesion, are everted and pulled transanally to outside the body. Only washout of and wiping off the distal rectum and intestinal resection are performed extracorporeally. The distal rectum is pushed back through the anus into the pelvis, and intracorporeal anastomosis is completed laparoscopically with a double-stapling technique. Our limited experience suggests that the prolapsing technique helps to prevent problems with laparoscopy-assisted LAR in selected patients with low rectal cancer.

Does Rectal Washout During Anterior Resection Prevent Local Tumor Recurrence?

Does Rectal Washout During Anterior Resection Prevent Local Tumor Recurrence?

Does Rectal Washout During Anterior Resection Prevent Local Tumor Recurrence?

Does Rectal Washout During Anterior Resection Prevent Local Tumor Recurrence?

Irrigation Volume Determines the Efficacy of “Rectal Washout”

Rectal stump washout has been recommended to prevent implantation of exfoliated malignant cells in the anastomosis after anterior resection for rectal cancer. The aim of this study was to investigate its efficacy, particularly the extent to which the volume of irrigation fluid might influence the efficacy of tumor cell elimination and whether tumor characteristics might influence the result. The study comprised 30 consecutive patients operated on by anterior resection for rectal cancer. After cross-clamping the rectum below the tumor, a washout sample was collected for examination after every incremental 500 ml of saline irrigation up to 2 liters. The presence of shed cancer cells was correlated with the washout volume and tumor characteristics. Cancer cells were found in 29 of 30 patients (97 percent) in the first sample of irrigation fluid and decreased gradually in frequency and number with increasing irrigation volumes. No cancer cells were demonstrated after 1.5 liters of irrigation in patients with tumor below the peritoneal reflection, whereas cancer cells were still present in one-fourth of the patients with tumor located above the peritoneal reflection. Finally, only a small number of cancer cells was confirmed in one patient after 2 liters of irrigation. The irrigation volume determined the efficacy of rectal washout. With our method, 1 1/2 liters of saline irrigation appears to clear contents from cancer cells in patients with tumors below the peritoneal reflection whereas at least 2 liters is recommended for patients with tumor above the peritoneal reflection.

Management of rectal injuries

Rectal injuries result from a variety of insults and cause a heterogeneous spectrum of injuries to patients. Historically, many of these injuries were devastating, with high morbidity and mortality. They often required an aggressive approach to treatment including fecal stream diversion, distal rectal washout, and presacral drainage. Contemporary surgical care and a better understanding of the management of these injuries have dramatically improved outcomes. Although aggressive management including diversion is still the gold standard for treatment of severe injuries, some civilian injuries may require less aggressive management, including nonoperative management. By examining most studies published on rectal injuries in the last 50 years, this comprehensive review examines the incidence, demographics, mechanisms, associated injuries, diagnostic methods, and treatment recommendations. Rectal injuries remain a complex and challenging problem for the surgeon, and a thorough understanding of this disease process as well as the treatment options available is necessary to ensure a safe and successful outcome for the patient.