Rigid Sigmoidoscopy Research Articles

SP8.12 - Evaluating the pig tissue model for acute proctology simulation at General Surgery ST3 Bootcamp

Abstract Evaluating the pig tissue model for acute proctology simulation at General Surgery ST3 Bootcamp Background Acute proctology is an important skill for any general surgical trainee; however it is a skill which often is overlooked when it comes to training. Most, if not all teaching happens during patient procedures. Simulation in this area is underdeveloped and there is a lack of validated models for simulation. These models are also usually expensive and difficult to obtain. The aim of this study was to assess face validity of a low-cost model for teaching acute proctology during the ST3 general surgical bootcamp. Methods We created a model using a pig rectum and perineum. This provided two uses. Firstly, we were able to teach relevant clinical anatomy. Secondly, we were able to simulate EUA, rigid sigmoidoscopy, decompression of volvulus and haemorrhoidal banding. The models allowed for repeated use. Results Twenty-five trainees took part in this simulation. Overall, the trainees felt the rectal examination was realistic (76%), the sigmoidoscope moved realistically in the model (72%) as did the proctoscope (88%). In terms of ability, trainees felt the simulation improved their confidence in EUA (68%), rectal examination (72%) and banding (80%). A total of 80% of trainees thought the model was overall “Good or Excellent”. Conclusions Our study demonstrates that this low-cost, high-fidelity simulation model has a high face validity and may be explored for the use for training new general surgical registrars.

Validation of a Tool-Based Visual Anorectal Examination Advanced Simulator for the Early Detection of Colorectal Cancer.

Rectal examination through proctoscopy or rigid sigmoidoscopy is a common investigation in clinical practice. It is an important diagnostic tool for the workup and management of anorectal pathologies. Performing the examination can be daunting not only for patients but also for junior doctors. There are associated risks with the procedure, such as pain, diagnostic failure, and perforation of the bowel. Simulation-based training is recognised as an important adjunct in clinical education. It allows students and doctors to practice skills and techniques at their own pace in a risk-free environment. These skills can then be transferred to and developed further in clinical practice. There is extensive research published regarding the role of simulation-based training in endoscopy, however, we identified no published study regarding simulation-based training in rigid sigmoidoscopy or proctoscopy. This study aims to establish the initial face, content, and construct validity of a tool-based visual anorectal examination advanced simulator model for proctoscopy and rigid sigmoidoscopy. This innovative, highly realistic simulated environment aims to enhance the training of healthcare professionals and improve the efficiency of detecting and diagnosing distal colorectal disease.

311 A Twist in the Tale - Study of the Management of Sigmoid Volvulus (SV)

Abstract Aim As SV has no current NICE guidance, nor large UK reviews, there is a requirement to outline best practice in the management. A review was undertaken of SV cases to determine how variation in management affects outcomes. Method Forty five patients (35:10 M:F) (median age 79 years, 29-93) with SV contributing 95 admissions 2017-2019 were studied using electronic notes and imaging. Estimated costs per patient were calculated using national tariff documents. Results Two groups were identified: conservative (non-operative management) (n = 39) and operative (n = 6), with a 90-day mortality of 41.02% and 16.67% respectively. Mean total days in hospital for each patient was 28.49 (range 1-215), 18.17 for operative and 30.08 for conservative. Nineteen patients had readmissions for SV 2017-2019, 30 in 2013-2021. No readmissions occurred post-surgery. Estimated cost of SV admissions 2017-2019 was £934,151, with no significant difference in cost for operative versus conservative. Rigid sigmoidoscopy was performed in 65.26% (n = 62) of admissions, 38.71% (n = 24) were successful. Flexible sigmoidoscopy was performed in 61.05% (n = 58) of admissions, 17 without rigid. Decompression was achieved in 72.41% (n = 42) with flexible more successful than rigid sigmoidoscopy (p = <0.0001). Conclusions SV patients are mostly male, older, co-morbid and managed conservatively. Mortality is high but reduced in patients managed surgically. Without surgery, patients had multiple admissions, decompressions, and long hospital stays, leading to increased costs. This project recommends the consideration of surgery in order to improve patient outcomes. A prospective large-scale study is required to improve data.

Skills for the aspiring surgeon in Australia: A needs assessment

Introduction: The increasing duration of time before the commencement of formal surgical education training (SET) in Australia has emphasised the need for pre-SET “aspiring” surgical trainees to develop greater competency in both generic and specialty-specific skills to fulfil these public hospital positions, however there is no formalised curriculum or guide. This paper investigates current inconsistencies in the training of Australian pre-SET aspiring surgical trainees and attempts to define which skills are required. Methods: We conducted semi-structured interviews with pre-SET supervisors in general and specialty surgery fields at a large tertiary teaching hospital in Sydney, Australia, to assess expectations and competencies of pre-SET surgical trainees. A mixed-method analysis was used with inductive content analysis used for the rich interview data and quantitative analysis of 5-point Likert scale scores for the essential skills syllabus and eligibility requirements. Results: Eighteen interviews were conducted. Three major themes arose from inductive content analysis: participants perceived that pre-SET trainees met basic expectations, significant variability in skill level exists between trainees, and simulation was suggested as a potential solution to address gaps in training. Quantitative analysis of Likert scores suggests that trainee competency was inadequate (or not required) for several skills. For general surgery, trainee competency was deemed inadequate for proctoscopy, rigid sigmoidoscopy and appendicectomy. Conclusions: There is a critical need to clearly define the skills expected of pre-SET trainees and their role within the healthcare system. This study provides insights into the content of that skillset, which could be used to design relevant and useful training programs for pre-SET trainees. The value of simulation training was universally noted by participants. They believed that this could improve competency for pre-SET trainees in technical and non-technical skills.

EP-555 The telescoping sigmoid – a rare presentation of acute large bowel obstruction

Abstract Background Adult bowel intussusception is a rare cause of bowel obstruction (1–5%) and requires urgent treatment, usually emergency surgery. Aim We wish to highlight the diagnosis and management of the rare entity of acute bowel obstruction secondary to intussusception with our adult patient with sigmoid colon intussusception. Case presentation We present a 65 years old male who attended with constipation, abdominal discomfort and per-rectal bleeding. Clinical examination revealed multiple subcutaneous lipomas, mild LUQ tenderness and large ‘lump’ 10 cm from anal verge on rigid sigmoidoscopy. CT abdomen/pelvis showed intussusception of the sigmoid into the rectum with a large ‘polyp’ as the lead point. On- table Flexible sigmoidoscopy was unsuccessful in reducing the intussusception. We proceeded to laparotomy with reduction of intussusception, high anterior resection with end- to- end stapled anastomosis. He made an excellent recovery. Post-operative histology which was reviewed in detail in MDT did not reveal any neoplastic/lipomatous lesion to account for the intussusception. The patient was very well on outpatient review. Conclusion Adult bowel intussusception is rare (5% of all intussusceptions), especially in the left colon. When it does occur, it is usually secondary to lipoma, neoplasm, or nodal mass acting as a lead point. These patients can be diagnostically challenging due to lack of clear obstructive symptoms on presentation. Early diagnosis (via a CT scan) and treatment of adult colonic intussusception (usually via surgery) is necessary to avoid serious complications such as bowel perforation/peritonitis. Postoperative histology review is also imperative to plan any appropriate further management.

SP3.1.3 Optimum treatment for sigmoid volvulus remains elusive but surgery may provide considerable benefit

Abstract Background Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking. Methods A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015–20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations and treatment were recorded. Results Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively. Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients). Conclusion Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.

Sigmoid volvulus in pregnancy: Current approach in diagnosis and treatment

Background/Aim: Sigmoid volvulus (SV) is an uncommon disease worldwide, while SV complicating pregnancy is extremely rare. The aim of this study is to evaluate the current diagnostic and therapeutic options in SV during pregnancy in a case series. Methods: The clinical data of 1,046 patients with SV, including 11 pregnant women, were reviewed retrospectively. Age, gestation period, previous history of volvulus, presence of comorbidities, duration of complaints, symptoms, signs, diagnostic tools, treatment procedures and prognosis were noted. Rigid or flexible sigmoidoscopy and magnetic resonance imaging (MRI) were used in the diagnosis, while abdominal X-ray and computerized tomography (CT) were avoided. Stable patients were treated with endoscopic decompression, while emergent surgery was needed in complicated cases with necrosis, peritonitis, or unsuccessful endoscopic decompression. Results: The mean age was 31.0 years (24-39 years). All cases were multiparous. Of the patients, 6 (54.5%) were in third trimester, 4 (36.4%) were in second trimester, and 1 (9.1%) was in first trimester. SV was diagnosed by endoscopy in 6 patients (54.5%), by magnetic resonance imaging (MRI) in 2 (18.2%), and during laparotomy in 3 (27.3%) patients. 6 patients (54.5%) were decompressed by sigmoidoscopy, while 5 cases (45.5%) were treated with surgery. One patient (9.1%) was lost due to toxic shock arising from sigmoid necrosis, while a stillbirth (9.1%) was developed following the surgical procedure in the same case. Conclusion: Although common findings including abdominal pain, obstipation and distention are prominent clinical features of SV, some clinical findings of pregnancy may cloud the pathology during pregnancy. We recommend sigmoidoscopy or MRI in the diagnosis of pregnant patients with suspected SV. Although enlarged uterus is generally thought as an impediment factor for endoscopic decompression, flexible sigmoidoscopy is currently preferred in the treatment of uncomplicated and non-gangrenous patients, while gangrenous or complicated cases are required emergency surgery regardless of the gestation period.

127 Optimum Treatment for Sigmoid Volvulus Remains Elusive but Surgery May Provide Considerable Benefit: Results of a 5-Year Audit

Abstract Background Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking. Method A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015-20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations, and treatment were recorded. Results Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively. Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients). Conclusions Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.

Is There a Precise Correlation between the Lengths of the Peritoneal Reflection and the Middle Rectal Valve?

Abstract Introduction Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries.

Health-related quality of life in patients with long-standing ulcerative colitis in remission.

Introduction:Ulcerative colitis (UC) contributes to impaired health-related quality of life (HRQoL). Although disease activity is the most important factor, reduced HRQoL has been reported even in quiescent UC. We aimed to determine HRQoL, and identify predictors thereof, in patients with long-standing UC in remission.Methods:In total, 66 patients with inactive UC were included 10 years after the disease onset. Clinical assessment including rigid sigmoidoscopy was performed to ensure remission. Data on demographic, clinical, treatment-related, and psychological determinants of HRQoL were obtained with a structured interview and self-assessment questionnaires measuring gastrointestinal (GI) and psychological symptoms and fatigue. HRQoL was measured with the Short Form Health Survey (SF-36).Results:The SF-36 domains were comparable to the general Swedish population, except for Vitality, where UC patients scored lower. Gender, smoking, comorbidity, or disease phenotype had no impact on HRQoL. In contrast, corticosteroid use and sick leave during the previous year were independently associated with Physical Functioning and Bodily Pain domains of SF-36; persisting GI symptoms during remission with Bodily Pain; and fatigue with Role Physical, General Health and Vitality. For all other SF-36 domains reflecting mental HRQoL (Social Function, Role Emotional, Mental Health), only psychological distress contributed uniquely.Conclusions:Although overall HRQoL in long-standing UC in remission is comparable to the general population, previous disease activity as well as persisting GI symptoms, fatigue, and psychological distress are associated with a lower HRQoL among these patients. Improved HRQoL may allow for better UC patient health and reduced costs for health care.

Condomless receptive anal intercourse is associated with markers of mucosal inflammation in a cohort of men who have sex with men in Atlanta, Georgia.

IntroductionWe previously showed that the rectal mucosal immune environment among men who have sex with men (MSM) engaging in condomless receptive anal intercourse (CRAI) is immunologically distinct from that of men who do not engage in anal intercourse (AI). Here, we further examined these differences with quantitative immunohistochemistry to better understand the geographic distribution of immune markers of interest.MethodsWe enrolled a cohort of MSM engaging in CRAI (n = 41) and men who do not engage in AI (n = 21) between October 2013 and April 2015. Participants were healthy, HIV‐negative men aged 18–45 from the metro Atlanta area. We performed rectal mucosal sampling via rigid sigmoidoscopy during two study visits separated by a median of nine weeks and timed with sexual activity for MSM engaging in CRAI. We used standardized, automated immunohistochemistry and quantitative image analysis to investigate the rectal mucosal distribution of neutrophils (MPO), IL‐17‐producing cells (IL‐17) and Tregs (FOXP3) in the lamina propria, and cellular proliferation (Ki67) and adherens junction protein (E‐cadherin) in the epithelium. We examined associations between biomarker expression and the rectal mucosal microbiota composition by 16s rRNA sequencing.ResultsRelative to the colonic crypt base, IL‐17, FOXP3, and MPO expression increased towards the rectal lumen, while Ki67 decreased and E‐cadherin was more uniformly distributed. Throughout the rectal mucosa distribution examined, MSM engaging in CRAI had higher mean lamina propria MPO expression (p = 0.04) and epithelial Ki67 (p = 0.04) compared to controls. There were no significant differences in IL‐17, FOXP3 or E‐cadherin expression. We found no significant associations of the five biomarkers with the global rectal microbiota composition or the individual taxa examined.ConclusionsUnderstanding the mucosal distribution of inflammatory mediators can enhance our knowledge of the earliest events in HIV transmission. Neutrophil enrichment and crypt epithelial cell proliferation likely represent sub‐clinical inflammation in response to CRAI in the rectal mucosa of MSM, which could increase the risk for HIV acquisition. However, the contributory role of the microbiota in mucosal inflammation among MSM remains unclear. HIV prevention may be enhanced by interventions that reduce inflammation or capitalize on the presence of specific inflammatory mechanisms during HIV exposure.

An Observational Analysis of a Novel Digital Rectoscope.

This is an analysis of the first 50 in-human uses of a novel digital rigid sigmoidoscope. The technology provides digital image capture, telemedicine capabilities, improved ergonomics, and the ability to biopsy under pneumorectum while maintaining the low cost of conventional rigid sigmoidoscopy. The primary outcome was adverse events, and the secondary outcome was diagnostic view. Fifty patients underwent outpatient (n = 25) and surgical rectal assessment (n = 25), with a mean age of 60 years. This included 31 men and 19 women with 12 different clinical use indications. No adverse events were reported, and no defects were reported with the instrumentation. Satisfactory diagnoses were obtained in 48 (96%) of 50 uses, images were captured in 48 (96%) of 50 uses, and biopsies were successfully taken in 13 uses (26%). No adverse events were recorded. Independent reviewers of recorded videos agreed on the quality and diagnostic value of the images with a κ of 0.225 (95% CI, 0.144-0.305) when assessing whether the target pathology was adequately visualized. The improved views afforded by digital rectoscopy facilitated a satisfactory clinical diagnosis in 96% of uses. The device was successfully deployed in the operating room and outpatients irrespective of bowel preparation method, where it has the potential to replace flexible sigmoidoscopy for specific use cases. The technology provides a high-quality image and video that can be securely recorded for documentation and medicolegal purposes with agreement between blinded users despite a lack of standardized training and heterogenous pathology. We perceive significant impact of this technology for the assessment of colorectal anastomoses, the office management of colitis, "watch and wait," and for diagnostic support in rectal cancer diagnosis. The technology has significant potential to facilitate proctoring and training, and it now requires prospective trials to validate its diagnostic accuracy against more costly flexible sigmoidoscopy systems.

Outcome of fecal incontinence in the two-staged seton fistulotomy for complex fistula in ANO.

Objective: To determine the frequency of fecal incontinence in the two-staged Seton fistulotomy in complex fistula in ano. Study Design: Prospective Cohort study. Setting: Surgical Out-patient Department at Shaikh Zayed Hospital Lahore. Period: September 2015 till March 2016. Material & Methods: After ethical review board approval, data was collected from 100 patients who fulfilled the inclusion criteria. All the procedures were conducted in the lithotomy position, under spinal or general anesthesia. A rigid sigmoidoscopy and proctoscopy was done prior to intervention. Fistula tract was marked using hydrogen peroxide (H202) for the identification of the internal opening. The external opening was gently probed using a standard 3 mm blunt-tipped probe till the internal opening was reached. The portion of the track outside the sphincter mechanism and any lateral tracts were laid open. A feeding tube of size 5 French was loosely tied around the remaining muscular portion of the sphincter complex. The seton was left in place for six weeks followed by secondary fistulotomy. Patients were evaluated for incontinence one month after the second procedure. Results: In our study, mean age was calculated as 47.38+10.96 years, 73%(n=73) were male and 27%(n=27) were females, frequency of fecal incontinence in the two-staged Seton fistulotomy in complex fistula in ano was recorded in 17%(n=17). Conclusion: The frequency of fecal incontinence in the two-staged seton fistulotomy for complex fistula in ano was acceptable in our study population and in tandem with literature. The procedure may be a suitable alternative to loose-seton placement alone.

Investigation on the status quo of diagnosis and treatment related to the protection of defecation function in sphincter-preserving resections for rectal cancer: a cross-sectional study of Chinese colorectal surgeons

Objective: To understand the current status of diagnosis and treatment regarding the protection of defecation function in Chinese surgeons performing sphincter-preserving resections (SPR) for rectal cancer in order to discover the problems existing in the function protection during SPR and provide support and reference for the standardized clinical management of rectal cancer. Methods: A cross-sectional survey was performed. Colorectal surgeons who obtained the medical qualifications and volunteered to participate in this study were included, and respondents with incomplete information were excluded. From October 18 to 22, 2020, randomized sampling was conducted among Chinese colorectal surgeons from Chinese Association of Colorectal Surgeons, Chinese Colorectal Cancer Committee, Chinese Sexology Association Anal functional Surgery Committee and National Health Commission Capacity Building and Continuing Education Committee. The questionnaire included basic information of the respondents, assessment of defecation function before SPR, intraoperative details, postoperative follow-up, evaluation and intervention of patients with low anterior resection syndrome (LARS). Observation indicator: results of the questionnaire survey. Result: A total of 231 questionnaires were collected, and 230 were effective, with an effective rate of 99.6%. Among these participants, 217 (94.3%) were males; 107 (46.5%) had medical doctor degrees; 129 (56.1%) were national commission members in colorectal surgery; 137 (59.6%) performed more than 50 SPR operations per year; 211 (91.7%) assessed defection function by auxiliary examinations before SPR. Rigid sigmoidoscopy (n=116, 55.0%) and anorectal manometer (n=81, 38.4%) were the most commonly used method. Among the 230 respondents, 64.8% (n=149) of surgeons used 2D laparoscopy for SPR surgery most commonly, and 51.3% (n=118) of surgeons performed direct colorectal anastomosis for reconstruction, and 98.3% (n=226) used staplers during anastomosis. All the surgeons indicated that they would follow up patients after SPR, and outpatient clinic was the most common method (84.4%, 184/230). When LARS occurred, 50.0% (115/230) of surgeons chose defecation function scale and 78.7% (181/230) actively provided guidance and intervention for patients. Conclusions: Chinese colorectal surgeons still have shortcomings in the protection of defecation function during SPR for rectal cancer. They do not make enough preoperative functional evaluation and postoperative functional recovery estimate for patients. The knowledge and use of defecation function scales and interventions on LARS are expected to be standardized.

Evaluation of adult cases presenting with bleeding per rectum

Background: Aim of the study was to find out various proportion of diseases responsible for bleeding per rectum in adults and to find out diagnostic utility of anoproctoscopy, rigid sigmoidoscopy and colonoscopy for patients with bleeding per rectum. It also aims to find out the usefulness of other investigations like upper GI scopy, computed tomography etc., in undiagnosed cases.Methods: A total no of 129 patients with complaint of bleeding per rectum were included in the study. All cases were subjected to anoproctoscopy and rigid sigmoidoscopy. Colonoscopy was done in cases with severe or recurrent bleeding which were undiagnosed by sigmoidoscopy. If colonoscopy does not reveal the diagnosis upper GI scopy or computerized tomography (CT) angiography was done.Results: At the end of evaluation of 129 cases with bleeding per rectum, the cause for bleeding identified in 101 cases (78.3%). 28 cases (21.7%) remain undiagnosed.Conclusions: Large bowel endoscopy increases the diagnostic yield in patients with bleeding per rectum. Rigid sigmoidoscopy is a safe OPD based procedure, recommended in all patients presenting with bleeding per rectum and if the cause for bleeding per rectum cannot be diagnosed by rigid sigmoidoscopy, then colonoscopy is indicated. Even colonoscopy is not diagnostic, then the other investigations like upper GI scopy and CT angiography can be done to identify the source of bleeding.

S1664 Colonic Obstruction Caused by GB Stone

INTRODUCTION: Colonic gallstone ileus is one of the rare causes of intestinal obstruction. These stones usually require surgery although endoscopic removal by different methods; such as extracorporeal lithotripsy, Dormia baskets and polypectomy snares have been described. CASE DESCRIPTION/METHODS: A 69-year-old female with no significant past medical history presented with several days of lower abdominal pain, nausea, vomiting, constipation and abdominal distension. There was no h/o hematemesis, melena or jaundice. She reported no previous colonoscopy. On exam, the patient was found to be in abdominal discomfort. No icterus or pallor was present. Abdominal exam showed distension with tenderness present in the left iliac fossa. Lab results were WBC 19.6, hemoglobin 6.0, platelets 340, total bilirubin 0.9, alkaline phosphatase 84, AST 12, ALT 8, Lactate 8.6. Fecal occult blood was negative. CT abdomen showed significant edema of the proximal colon, pneumobilia with 3.7 cm lamellated calcified lesion resembling a large gallstone present in the distal sigmoid colon resulting in local mechanical obstruction. The patient was diagnosed with gallstone colonic ileus and cholecystocolonic fistula. She underwent attempted removal of stone with the help of rigid sigmoidoscopy and then flexible colonoscopy, but both failed. Finally, she underwent open laparotomy and extended sigmoid colectomy, Hartmann’s procedure and colostomy. The cholecystocolonic fistula was not disturbed. She had a good recovery and was discharged in stable condition after 5 days. At around 6 months, she underwent a biliary scan which showed that the cholecystocolonic fistula had closed spontaneously. She subsequently underwent reversal of the Hartmann procedure and cholecystectomy. Currently she is doing well with no recurrence. DISCUSSION: Large bowel ileus due to gallstone is a rare cause of obstruction. The stone reaches the colon most commonly through cholecystocolonic fistula. The impacted area is usually at a point of pathological narrowing, such as related to diverticular disease, as in our patient. The patient typically presents with abdominal distension, pneumobilia and ectopic stone all of which were present in our patient. CT abdomen is the investigation of choice. Endoscopic Dormia basket removal has been successfully used in the past by authors. But when the stone is too large, surgical removal of the stone may be necessary. The cholecystocolonic fistula also needs to be repaired at a later date which may require surgical re-exploration.Figure 1.: Colonoscopic view showing large Gall Bladder stone in Sigmoid colon.Figure 2.: CT scan abdomen showing the radio-opaque GB stone in the sigmoid colon.

How to accurately measure the distance from the anal verge to rectal cancer on MRI: a prospective study using anal verge markers.

To determine an accurate method for localizing rectal cancer using the distance from the anal verge on preoperative MRI. This prospective study included 50 patients scheduled for MRI evaluation of rectal cancer. After rectal filling with gel, MRI was performed with two markers attached at the anal verge. The distance between the tumor and the anal verge on a sagittal T2-weighted image (T2WI) was measured independently by two radiologists using six methods divided into three groups of similar measurement approaches, and compared to those obtained on rigid sigmoidoscopy. The anal verge location relative to the external anal sphincter was assessed on oblique coronal T2WI in reference to the markers. Correlation analysis was performed using the intraclass correlation coefficient (ICC) for verification, and a paired t test was used to evaluate the mean differences. The highest correlation (ICC 0.797-0.815) and the least mean difference (0.74-0.85cm) with rigid sigmoidoscopy, and the least standard deviation (3.12-3.17cm) were obtained in the direct methods group using a straight line from the anal verge to the tumor. The anal verge was localized within a range of - 1.4 to 1.5cm (mean - 0.31cm and - 0.22cm) from the lower end of the external anal sphincter. The direct methods group provided the most accurate tumor distance among the groups. Among the direct methods, we recommend the direct mass method for its simplicity. Despite minor differences in location, the lower end of the external anal sphincter was a reliable anatomical landmark for the anal verge.

To study postoperative complications between circular stapler hemorrhoidopexy and conventional hemorrhoidectomy

Method: Per-rectal examination with gentle dilatation done after lubrication with xylocaine jelly. Rigid sigmoidoscopy is done to look for any pathology in recto sigmoid region. After doing preliminary painting and draping anal verge is held by three atraumatic forceps at the three points where the prolapse is smaller and the anoderm is slightly everted. Such a maneuver facilitates the introduction of circular anal dilator (CAD 33) after lubrication with xylocaine-Jelly. The introduction of the circular anal dilator-33 along with the obturator cause the reduction of the prolapse of the anoderm and points of anal mucous membrane. After removing the obturator prolapsed. All remaining prolapsing tissue should be pushed back with atraumatic forceps through the window of the circular anal dilator-33.Result: The comparison of mean age between the open hemorrhoidectomy and stapler hemorrhoidopexy groups. The mean age in the open hemorrhoidectomy group was 41.00 ± 6.47 years and in the stapler hemorrhoidopexy group was 41.55 ± 11.38 years. The comparison of age between the two groups was found to be statistically not significant (p>0.05), showing a comparable age between the two groups. Reactionary hemorrhage was seen in 30% patients of open hemorrhoidectomy, while it was seen in 20% patients of stapler hemorrhoidopexy group. There was a statistically no significant association seen between reactionary hemorrhage and the groups (p>0.05), showing a comparable distribution of patients with reactionary hemorrhage in both the groups.Conclusion: In stapler hemorrhoidopexy functional outcome is good as compared to conventional hemorrhoidectomy. Stapler hemorrhoidopexy is associated with less morbidity with fewer complications due to minimal tissue trauma and handling. Although the conventional hemorrhoidectomy is still performed in many higher centers but in this era of minimal invasive surgery the stapler hemorrhoidopexy is fast replacing the conventional hemorrhoidopexy.

Contemporary management of rectal trauma - A South African experience

IntroductionThe management of rectal trauma remains controversial. There are three modalities which have been used to manage these injuries; proximal diversion (PD), washout of the distal rectum (DRW) and presacral drainage (PSD). The EAST group tentatively advocate mandatory proximal diversion for extraperitoneal rectal injuries and omitting DRW or PSD. Other authors have suggested that diversion can be eschewed in patients with an intraperitoneal injury which can be primarily repaired. In light of all these controversies, this project set out to review our experience with rectal injuries over the last seven years with the objective of reviewing our use of PD, PSD and DRW. MethodsPatients aged greater than or equal to 15 years with rectal injuries during December 2012 to July 2019 were included. Patient demographics, mechanism of injury, management strategy (operative or non-operative), complications, patient residential status (urban or rural), hospital and intensive care duration of stay, and 30-day mortality rates were assessed. ResultsDuring the study period, a total of 51 patients with a rectal injury were treated. There were 45 (88%) males and the median age was 29 (22-39) years. There were 7 (14%) blunt mechanisms, 41 (80%) penetrating mechanisms and 3 (6%) combined blunt and penetrating mechanisms. The median ISS was 13 (9-18). Of the 50 rectal injuries ultimately treated at our institution, there were 31 extraperitoneal and 14 intraperitoneal injuries. There were five combined intra and extraperitoneal injuries. A total of 21 rigid sigmoidoscopies and a single flexible sigmoidoscopy were performed. A total of 24 patients underwent a CT scan. There were 13 primary repairs and 45 PD. A single patient required a PSD. Of the 34 documented complications, 15 (44%) were related to sepsis and can be attributed to the rectal injury. The overall mortality rate was 11.8%. ConclusionsRectal injuries are associated with significant septic related morbidity and mortality. Although we have begun to avoid diversion in a small subset of patients with an intraperitoneal injury, we continue to perform PD for the vast majority of patients with a rectal injury. We do not perform DRW and PSD is used in highly selective cases.

Rigid Sigmoidoscopy is Superior to CT for Diagnosing Penetrating Rectal Injury

Rigid Sigmoidoscopy is Superior to CT for Diagnosing Penetrating Rectal Injury