Andrew Luck

Effects of video information on precolonoscopy anxiety and knowledge : a randomised trial

BACKGROUND The provision of information before medical or surgical procedures should improve knowledge and allay anxiety about the pending procedure. This trial aimed to assess the value of an information video in this process. METHODS Patients scheduled to undergo colonoscopy were approached about 1 week before the procedure. All patients were given an information leaflet about colonoscopy, and completed a Spielberger state anxiety inventory (STAI) questionnaire to assess baseline anxiety. The patients were then randomly assigned to watch or not watch the information video. Immediately before colonoscopy, all patients completed a second anxiety questionnaire and a knowledge questionnaire. FINDINGS 198 patients were screened. 31 declined to participate and 17 were unable to complete the forms. Of the remaining 150 patients, 72 were assigned the video, and 78 no video. The groups were similar with regard to age, sex, educational attainment, and initial anxiety score. Female patients had higher baseline anxiety than male patients (mean STAI 46.3 [95% CI 44.9-47.7] vs 36.9 [35.5-38.3]; difference 9.4 [7.8-12.2], p=0.0008). Patients who had not had a previous colonoscopy had higher baseline anxiety scores than those who had prior experience of the procedure (46.9 [45.4-48.5] vs 36.3 [34.7-37.9]; difference 10.6 [7.5-13.8], p=0.0008). Patients who watched the video were significantly less anxious before colonoscopy than those who did not. The former also scored more highly in the knowledge questionnaire than the latter with regard to the purpose of the procedure, procedural details, and potential complications of colonoscopy. INTERPRETATION An information video increases knowledge and decreases anxiety in patients preparing for colonoscopy.

Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial.

INTRODUCTION: Glyceryl trinitrate has been shown to be an effective treatment for chronic anal fissure. It decreases anal tone and ultimately heals anal fissures. The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy (current standard treatment) as definitive management for chronic anal fissure. METHODS: All patients with symptoms of chronic anal fissure were randomly assigned to one of two treatment arms. The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks. Patients in the lateral sphincterotomy group underwent surgery on the next available operating list. Patients were reviewed at two weekly intervals until the fissure healed. RESULTS: Sixty‐five patients were enrolled in the trial, with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group. Five patients were excluded after randomization. Twenty of 33 (60.6 percent) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 (97 percent) in the sphincterotomy group (P =0.001). Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy. Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate. Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment (P =0.0001). Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures. There were no long‐term complications from lateral sphincterotomy. CONCLUSION: Glyceryl trinitrate paste heals the majority of chronic anal fissures. However, a significant minority have little improvement or develop side effects and require conventional surgical treatment. Poor compliance with prescribed treatment often contributes to nonhealing. In addition, some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment. Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy.INTRODUCTION: Glyceryl trinitrate has been shown to be an effective treatment for chronic anal fissure. It decreases anal tone and ultimately heals anal fissures. The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy (current standard treatment) as definitive management for chronic anal fissure. METHODS: All patients with symptoms of chronic anal fissure were randomly assigned to one of two treatment arms. The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks. Patients in the lateral sphincterotomy group underwent surgery on the next available operating list. Patients were reviewed at two weekly intervals until the fissure healed. RESULTS: Sixty-five patients were enrolled in the trial, with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group. Five patients were excluded after randomization. Twenty of 33 (60.6 percent) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 (97 percent) in the sphincterotomy group (P=0.001). Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy. Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate. Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment (P=0.0001). Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures. There were no long-term complications from lateral sphincterotomy. CONCLUSION: Glyceryl trinitrate paste heals the majority of chronic anal fissures. However, a significant minority have little improvement or develop side effects and require conventional surgical treatment. Poor compliance with prescribed treatment often contributes to nonhealing. In addition, some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment. Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy.

Ischiorectal fossa block decreases posthemorrhoidectomy pain

PURPOSE: Hemorrhoidectomy can be associated with severe pain in the immediate postoperative period. The aim of this study was to assess the efficacy of a preemptive local anesthetic, ischiorectal fossa block, in the reduction of pain and analgesic requirements after hemorrhoidectomy. METHODS: All patients were suitable for an established day surgery hemorrhoidectomy protocol. Immediately before surgery patients were randomly assigned either to receive (Group 1) or not receive (Group 2) the local anesthetic block. All other aspects of surgery and anesthesia were standardized. Nursing staff assessed pain at 30 minutes and 2, 4, and 24 hours postoperatively using a visual analog scale (1–10, where 1 represented no pain and 10 represented the worst pain imaginable). Analgesic requirements also were recorded at these times. Both the patients and the nursing staff were blinded to which local anesthetic protocol had been used. RESULTS: Twenty patients were enrolled in the trial. Ten patients were randomly assigned to Group 1 and ten to Group 2. Mean pain scores for Group 1 (anal block) at 0.5, 2, 4, and 24 hours were 1.5, 1.8, 2.1, and 2.5, respectively, compared with Group 2, with mean pain scores of 3.4, 3.4, 3.9, and 5.1. These differences were statistically significant. Patients in Group 1 used less analgesia in the first 24 hours postoperatively than those in Group 2. CONCLUSION: The use of a preemptive local anesthetic, ischiorectal fossa block, is associated with a significant decrease in pain and analgesia requirements after hemorrhoidectomy.

Positron‐emission tomography/computed tomography (PET/CT) in the initial staging of primary rectal cancer

Objective  The aim of this study was to assess the role of 18flourodeoxyglucose positron‐emission tomography/computed tomography (PET/CT) in the initial staging of primary rectal adenocarcinoma.

Transanal haemorrhoidal dearterialization for the treatment of grade III and IV haemorrhoids: a 3-year experience

Transanal haemorrhoidal dearterialization (THD) is increasingly perceived as an effective and better tolerated alternative to excisional haemorrhoidectomy. The aim of this study was to evaluate outcomes and the patient experience of THD in an Australian population with grade III or IV haemorrhoids.

The conundrum of quality in colonoscopy

While there is always interest in evaluating innovative new techniques, there is sometimes apathy for evaluating and improving the quality of standard surgical practice. The introduction of nationwide surgical mortality audits was an advance towards improved quality in surgery through reflection, accountability and continuing improvement. Credentialing of clinicians has not been shown to have an impact on quality of care or patient outcomes, and there is controversy over the use of threshold credentials, in which a minimum number of procedures are required for a clinician to obtain a particular scope of clinical practice. Similarly, the implementation of minimum procedure requirements for revalidation poses ethical considerations given our geographically disperse population. Rural surgeons conduct a broad casemix of procedural work in smaller centres, reducing the inconvenience and cost associated with patients needing to travel to larger centres. Restricting service provision to rural Australia by excluding clinicians based on procedure frequency will threaten the sustainability of rural health services and negatively impact outcomes for rural patients. An increasing focus on the quality of colonoscopic examination worldwide has lead to closer scrutiny of colonoscopy performance through audit of quality markers such as caecal intubation rate and adenoma detection rate (ADR). The focus on quality has formalized into recertification programmes in colonoscopy, such as in the UK where clinicians undertaking bowel cancer screening colonoscopies are required to undertake periodic recertification. These measures have resulted in excellent colonoscopy quality, with a mean ADR of 46.5% and a mean unadjusted caecal intubation rate of 95.2% in colonoscopies performed as part of the UK bowel cancer screening programme. While not yet mandatory, an Australian recertification programme for colonoscopy has been established, providing triennial recertification based on logbook requirements that include a minimum number of colonoscopies (150), adequate caecal intubation rate (95%) and ADR (25%). The National Bowel Cancer Screening Program (NBCSP) had prompted a renewed focus on quality in colonoscopy in Australia and it is interesting to note that the NBCSP is funding the voluntary recertification programme, leading to speculation that mandatory certification may be required to undertake NBCSP colonoscopies in the future. Questioning the need for recertification in colonoscopy prompted us to carry out a survey to investigate proceduralists’ knowledge of quality indicators in colonoscopy and assess attitudes towards recertification. An online questionnaire was distributed to Australian members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and Gastroenterological Society of Australia (GESA), yielding responses mainly from colorectal surgeons (68%). Self-awareness of performance in colonoscopy was good. Ninety-four percent of respondents were aware of their caecal intubation rate, and almost all (92%) reported an intubation rate above 95%. Similarly, 72% were aware of their ADR, and of these 79% quoted their ADR being above 20%. Conversely, endoscopy unitbased audit of outcomes was reported by only 51% of respondents. Among respondents that reported unit-based audit, outcomes recorded commonly were complications such as perforation rate (76%), with fewer units recording quality indicators such as caecal intubation rate (62%) and ADR (57%). The majority of clinicians did not object to mandatory recertification; only 18% disagreed to the prospect of periodic recertification in order to optimize quality in colonoscopy. Furthermore, respondents indicated that caecal intubation rate (81%), ADR (53%) and logbook submission (51%), would be the preferred criteria for recertification, which are all components of the existing voluntary recertification programme. In stratifying the risk of future adenoma and carcinoma risk the endoscopic surveillance interval is important. Guidelines, such as the Cancer Council Australia (CCA) guidelines exist to guide interval choice; however, adherence has previously been reported to be inadequate. The Medicare Benefits Schedule (MBS) Review Taskforce has recommended that MBS items for colonoscopy be altered to describe the appropriate indication for colonoscopy and surveillance interval. In our survey, all clinicians were aware of the CCA guidelines, with 93% following the guidelines ‘Always’ or ‘Most of the time’. Furthermore, the far majority feel that these surveillance intervals are appropriate, suggesting that such a change to the MBS would not impact the majority of clinicians. Although a survey has obvious limitations in assessing quality indices, this study has shown that overall knowledge regarding quality indicators and individual performance in colonoscopy is high. Clinicians are not opposed to recertification to maintain high quality of colonoscopic examination. There appear to be inconsistent auditing of colonoscopy performance by endoscopy units, raising the possibility that improved local auditing could negate the need for a future mandated recertification programme. Given the apparent high standard of colonoscopy demonstrated in this study, it could be postulated that changes to the MBS and the implementation of mandatory recertification may only result in incremental gains in quality indicators. Prior to the introduction of a mandatory recertification programme in colonoscopy, it is necessary to further consider the impact to low volume proceduralists, including those servicing rural areas.

B-cell lymphoma presenting as pneumatosis intestinalis: a case report

that this may not be feasible and surgical resection is necessitated. If surgical resection is performed, subsequent surveillance and follow-up is well described by NICE guidelines. However, there remains controversy as to the surveillance regimen of malignant polyps treated by endoscopic resection. The British Society of Gastroenterology/Association of Clinical Pathologists recommends endoscopic surveillance at 3 months, and in certain cases 9 months as well after the initial polypectomy. In other countries, the surveillance regimen is rather more intense. In the USA, endoscopic surveillance is performed at 3 months and then at 1, 3 and 5 years. Several studies have also recommended more frequent endoscopic surveillance in the short term with recurrence rates of up to 20%. In a pilot study at our District General Hospital over a 5-year period, there was a 14% local recurrence rate (2/14) within 12 months. As malignant polyps represent a different clinical entity to both colorectal cancer treated with surgical resection and benign polyps with various degrees of dysplasia, there is a distinct lack of evidence for the duration and frequency of an endoscopic surveillance regimen. This poses a difficult clinical dilemma and there are considerable variations in the investigations patients receive.

Prospective randomized trial of neoadjuvant chemotherapy during the ‘wait period’ following preoperative chemoradiotherapy for rectal cancer: results of the WAIT trial

The aim was to determine whether the addition of additional cycles of chemotherapy during the ‘wait period’ following neoadjuvant chemoradiotherapy for rectal cancer improves the pathological complete response (pCR) rate.