Alexis Schizas

Non-attendance at the colorectal clinic: a prospective audit

INTRODUCTIONnNon-attendance in the out-patient department has financial costs for the NHS and clinical implications to the non-attender and those awaiting an appointment. The aim of this audit was to quantify the percentage of non-attenders at colorectal clinics in a UK teaching hospital, assess which factors affected attendance, establish why individuals fail to attend and to implement appropriate change.nnnPATIENTS AND METHODSnThe number of did-not-attend patients was recorded initially for 686 appointments. Non-attenders were contacted by post or telephone to ask why this was so. The study was then repeated following telephone reminders to 391 patients due to attend clinic. The did-not-attend rates in the two limbs of the completed audit cycle were then compared.nnnRESULTSnThe initial study revealed a did-not-attend rate of 21%, with significantly more males than females failing to attend (males, 28.6%; females, 16.9%; P = 0.001). The did-not-attend rate was not significantly affected by the day of the week, time of appointment or by the weather. There were 51.7% responses to either the postal or telephone questionnaire regarding non-attendance. Of these, 27.7% did not receive an appointment letter or received it after the appointment. Hospital administration problems were cited as accounting for 34.2% of did-not-attends. In the post-intervention limb, 87 patients (22%) replied to the reminder telephone call, of whom 9 (10%) cancelled their appointment and 78 (90%) confirmed that they would attend. The did-not-attend rate fell to 19.7% although this was not a significant reduction.nnnCONCLUSIONSnTelephoning patients before their appointments is labour intensive and did not significantly improve the did-not-attend rate. Although hospital administration errors account for a significant number of the did-not-attends, patients also have a responsibility to notify the hospital if they are unable to attend.

Internal anal sphincter atrophy in patients with systemic sclerosis

OBJECTIVESnSSc is a connective tissue, multisystem disorder of unknown aetiology. The gastrointestinal tract (GIT) is affected in up to 90% of patients. The exact pathophysiology of GIT involvement is not known, but it is related to both neurogenic and myogenic abnormalities as well as possible vascular and ischaemic changes. Thinning of the internal anal sphincter (IAS) has been demonstrated in SSc with faecal incontinence. We aimed to investigate anal sphincter structure in patients with SSc.nnnMETHODSnForty-four SSc patients [24 symptomatic (Sx) and 20 asymptomatic (ASx)] and 20 incontinent controls (ICs) were studied. Patients underwent anorectal manometry and endoanal US.nnnRESULTSnIn the ICs, external anal sphincter defects were more common, but the IAS was less atrophic, evident by both atrophy scores and IAS thickness. There was no significant difference in atrophy scores [Sx: 2 (1.5-3) vs ASx: 2 (1-2)] or IAS thickness [Sx: 1.85 (1.5-2.3) vs ASx: 1.8 (1.7-2.25)] between the Sx and ASx SSc patients.nnnCONCLUSIONnPatients with SSc (both Sx and ASx) have thin and atrophic IAS, suggesting that IAS atrophy develops even in ASx patients and this may be amenable to treatment with sacral neuromodulation.

Anal carcinomas: the role of endoanal ultrasound and magnetic resonance imaging in staging, response evaluation and follow-up.

Anal carcinoma is an important but rare condition, managed in specialist centres. Both endoanal ultrasound and magnetic resonance imaging (MRI) can be used in the locoregional staging and follow-up of patients with anal cancer, and both may assist in treatment planning and prognosis. Recent guidelines published by the European Society for Medical Oncology have recommended MRI as the technique of choice for assessment of locoregional disease. This paper describes the techniques for both endoanal ultrasound and MRI, and compares the relative merits and disadvantages of each in the local assessment of anal carcinoma.

Initial experience of treating anal fistula with the Surgisis anal fistula plug

BackgroundComplex anal fistulas remain a challenge for the colorectal surgeon. The anal fistula plug has been developed as a simple treatment for fistula-in-ano. We present and evaluate our experience with the Surgisis anal fistula plug from two centres.MethodsData were prospectively collected and analysed from consecutive patients undergoing insertion of a fistula plug between January 2007 and October 2009. Fistula plugs were inserted according to a standard protocol. Data collected included patient demographics, fistula characteristics and postoperative outcome.ResultsForty-four patients underwent insertion of 62 plugs (27 males, mean age 45.6xa0years), 25 of whom had prior fistula surgery. Mean follow-up was 10.5xa0months Twenty-two patients (50%) had successful healing following the insertion of plug with an overall success rate of 23 out of 62 plugs inserted (35%). Nineteen out of 29 patients healed following first-time plug placement, whereas repeated plug placement was successful in 3 out of 15 patients (20%; pxa0=xa00.0097). There was a statistically significant difference in the healing rate between patients who had one or less operations prior to plug insertion (i.e. simple fistulas) compared with patients who needed multiple operations (18 out of 24 patients vs. 4 out of 20 patients; pxa0=xa00.0007).ConclusionsSuccess of treatment with the Surgisis anal fistula plug relies on the eradication of sepsis prior to plug placement. Plugs inserted into simple tracts have a higher success rate, and recurrent insertion of plugs following previous plug failure is less likely to be successful. We suggest the fistula plug should remain a first-line treatment for primary surgery and simple tracts.

Anal Canal Vector Volume Manometry

BACKGROUND: Anal manometry is routinely used in the assessment of the anal sphincters in patients with fecal incontinence or suspected sphincter injury. Such physiological information is complementary to the anatomical assessment provided by anal endosonography. The evolution of 3-dimensional anal endosonography provides more diagnostically useful information in complex cases. Vector volume manometry has been developed to give a 3-dimensional view of the anal sphincters. OBJECTIVE: We reviewed the published literature on this technique, with the intention of deriving a system of standardization based on the published literature and to summarize the derivation and physiological meaning of the parameters measurable by vector volume studies, as well. DATA SOURCES: We undertook a MEDLINE search using the terms “vector volume” or “vector manometry” and “anal canal.” We also reviewed further publications found from references cited in the original articles identified from the above search. STUDY SELECTION: Only English language articles of studies performed on humans were reviewed. INTERVENTION: Anal canal vector volume manometry was the intervention. RESULTS: With the development of automated puller systems and associated software, parameters such as total vector volume, maximum pressure, mean pressure, anal canal symmetry, anal canal length, and the length of the high-pressure zone can be readily calculated. LIMITATIONS: There are conflicting studies related to the clinical value of both anal manometry and vector volume manometry, in part, because of the lack of standardization of equipment and technique. CONCLUSONS: The vector volume parameters have been shown to correlate with both imaging results and incontinence scores with automated puller systems. The clinical utility of vector volume manometry would be improved further by the standardization of equipment and technique. The main clinical utility may lie in the treatment selection and preoperative assessment of patients awaiting surgery for anal pathology that has yet to be evaluated.

Colovesical Fistula: Should It Be Considered a Single Disease?

Purpose This research was conducted to compare the management and the outcome of patients with colovesical fistulae of different aetiologies. Methods Retrospective data were collected from 2002 to 2012 and analyzed with SPSS ver. 17. Age, gender, aetiology, management, hospital stay, postoperative complications, and mortality were studied and compared among colovesical fistulae of different aetiologies. Results A total of 55 patients, 46 males (84%) and 9 females (16%), with a median age of 65 years (interquartile range [IQR], 48-75 years) were studied. Diverticular disease was the most common benign cause and recto-sigmoid cancer the most common malignancy. Anterior resection and bladder repair were the most frequent operations in benign cases, as was total pelvic exenteration in the malignant group. Multiple intestinal loop involvement and subsequent resection were significantly higher in those with Crohn disease than it was in patients of colovesical fistula due to all other causes collectively (60% vs. 6%, P = 0.006). Patients with malignancy had a higher postoperative complication rate than patients who did not (12 [80%] vs. 7 [32%], P = 0.0005). Pelvic collection (11, 22%) was the most frequent early complication (predominantly in the malignant group) whereas incisional hernia (8, 22%) was the most common late complication, with a predominance in the benign group. The median hospital stay was significantly prolonged in the malignant group (32 days; IQR, 17-70 days vs. 16 days; IQR, 11-25 days; P < 0.001). Conclusion Despite their having similar clinical presentation, colovesical fistulae of various aetiologies differ significantly in management and outcome.

A review of functional pelvic floor imaging modalities and their effectiveness

The anatomy of the pelvic floor is complex and clinical examination alone is often insufficient to diagnose and assess pathology. With a greater understanding of pelvic floor dysfunction and treatment options, imaging is becoming increasingly common. This review compares three imaging techniques. Ultrasound has the potential for dynamic assessment of the entire pelvic floor. Magnetic resonance imaging is able to rapidly image the entire pelvic floor but it is expensive and tends to underestimate pathology. Dynamic defaecating proctography or cystocolpoproctography is the current gold standard for posterior compartment imaging but requires opacification of the bladder to provide a global view.

Endosonographic staging of lower intestinal malignancy

The use of EUS in the assessment of rectal pathology is well established. The accurate staging of lower intestinal tumours predicts prognosis and guides the planning of individual patient treatment. Increased experience and the development of high resolution three-dimensional EUS has lead to the greater accuracy of rectal staging with EUS of rectal tumours now considered the gold standard showing T stage accuracy that ranges from 75% to 95%, with N stage accuracy ranging from 65% to 80%. The use of EUS in the staging of colonic pathology, however, is not so well established though advances in miniprobe EUS has improved the assessment of colonic tumours. EUS is also of benefit in the assessment of anal pathology though here, accurate correlation with histology has not been firmly established.

Bleeding pseudoaneurysm of the internal iliac artery after extended resection for advanced rectal cancer: report of two cases

The incidence of locally advanced rectal cancer at diagnosis has increased despite surveillance programmes, especially among young patients [1]. Extended low anterior resection and pelvic exenteration after chemoradiotherapy have been described to be effective treatments for advanced primary or recurrent pelvic cancer although they are recognised to be technically demanding procedures associated with high morbidity and mortality rate [2]. Bleeding represents one of the most serious peri-operative complications, especially during pelvic exenteration. Secondary haemorrhage is much less common; to date, ruptured pseudoaneurysm of the pelvic arteries has not been described as a cause of massive postoperative rectal bleeding after surgery for advanced rectal cancer.

Vector volume manometry - methods and normal values

Backgroundu2002 Vector volume manometry (VVM) can be used to assess patients with fecal incontinence. The VVM may be performed using a station pull through, or an automated technique. Currently no standard technique or equipment exists to assess anal canal VVM. This study aimed to assess the different techniques to produce repeatable results, and generate normal values for the vector volume profile.