Assad Zahid

Pouch adenomas in Familial Adenomatous Polyposis after restorative proctocolectomy

INTRODUCTION Australian Clinical Practice Guidelines suggest six to twelve-monthly endoscopic pouch surveillance in patients after restorative proctocolectomy for Familial Adenomatous Polyposis (FAP). There are several reports of adenomas and carcinomas forming within the ileum, ileal pouch mucosa or residual rectal mucosa. A retrospective clinical study was performed to audit pouch endoscopic surveillance at a large Sydney tertiary referral Hospital. The aim was to evaluate adenoma development after restorative proctocolectomy for FAP and the adherence rate to published clinical guidelines. METHODS Thirty-nine patients who had restorative proctocolectomy for FAP from 1985 to 2011 were identified. Demographic data, details of surgery, original histopathology and details of follow-up pouch endoscopy and pathology findings were obtained. RESULTS Of the thirty-nine patients, twenty-seven patients were included in this study. Adenomas were found in twelve of 27 (44%) patients. Mean time to first polyp formation was 88 months and median time was 72 months (range 18-249 months). All polyps were either tubular or tubulovillous in histology. One polyp had high grade dysplasia. The remainder had mild or moderate dysplasia. Polyps were excised either endo-anally or during pouchoscopy. None of the five patients who had a hand-sewn ileal pouch-anal anastomosis (IPAA) developed polyps on follow-up, compared with 12 of the 22 (55%) with a double stapled anastomosis (fishers exact test; p=0.047 (two-tailed)). Of those who developed pouch adenomas, eight (67%) developed further pouch adenomas on follow-up. CONCLUSIONS This study supports guidelines recommending lifelong pouch surveillance after restorative proctocolectomy for FAP. Those who develop pouch adenomas may be at greater risk of developing further adenomas. Residual rectal mucosa at the pouch-anal anastomosis should be carefully examined.

Gum chewing aids bowel function return and analgesic requirements after bowel surgery: a randomized controlled trial

The aim was to compare the effectiveness of chewing sugar‐free gum after bowel resection on bowel function and length of stay.

A randomized controlled trial of four different regimes of biofeedback programme in the treatment of faecal incontinence

Biofeedback is an established, effective and non‐invasive treatment for faecal incontinence (FI). The aim was to compare the effectiveness of four different biofeedback treatment regimes.

Randomized controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post hoc cost analysis

In view of the increasing burden on the healthcare system, this study aims to perform a cost‐effectiveness analysis of the management of incurable large bowel obstruction comparing the cost of a stent vs surgery.

Coaching Experts: Applications to Surgeons and Continuing Professional Development

Surgery is a science and an art, which is mastered through years of training and refined by the accumulation of individual experience and preference. Continuing professional development (CPD) is a concept that emphasizes a self-directed approach to education. Coaching is a process that leads to increased utilization of a person’s current skills and resources without counselling or advising. Coaching in surgery could be used to facilitate and optimize feedback and reflection, thus enhancing performance and outcomes through elite performance of an operative procedure. Therefore, it can be applied under the umbrella of CPD. Ultimately also emphasizing that better quality surgery is not necessarily purely based on technical outcomes, it is a combination of both technical and nontechnical practice. Coaching of surgeons is a conceptually formidable tool in the successful implementation of effective CPD programs. CPD currently provides an opportunity for surgeons to gain access to constantly evolving medical knowledge and technique; however, there is no accountability to its understanding or implementation. Coaches have the potential to provide confidential appraisal and feedback in a constructive approach with the aim to eliminate any barriers to the transfer of technique and knowledge.

Peritoneal encapsulation as a cause of chronic recurrent abdominal pain in a young male

Abstract This case report describes an otherwise well 20-year-old male who presented to hospital with vague, long-standing abdominal symptoms and was found to have peritoneal encapsulation.

Reply to response to ‘Gum chewing aids bowel function return and analgesic requirements after bowel surgery: a randomized controlled trial’

We thank Lambrichts and Lange for their interest in our article (1). We agree that recovery of gut function is complex and that flatus alone or bowel motion alone may not be the best individual measures. It was not made clear in our paper but the primary end point was bowel emptying with a bowel motion that was Bristol stool type 1 to 6 (ie. not 7 - watery diarrhoea) as well as tolerating more than 50% of a solid diet. Unfortunately we did not record tolerating a diet as a separate end point. This article is protected by copyright. All rights reserved.

Karydakis procedure can be effectively performed in the lateral position: Karydakis procedure in the lateral position

Karydakis published a large pilonidal series in 1992, reporting a recurrence rate of less than 1% and complication rate of 8.5%. The aim of this study was to compare the outcomes of Karydakis procedure (KP) performed in the lateral versus the prone position in a consecutive series.

Colorectal surgeon consensus with diverticulitis clinical practice guidelines

AIM To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand. METHODS A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios. RESULTS The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher’s exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001). CONCLUSION While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.

Hypothesized summative anal physiology score correlates but poorly predicts incontinence severity

AIM To explore the relationship between such a construct and an existing continence score. METHODS A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed. RESULTS Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP (P = 0.0002), ACL (P = 0.0006) and pudendal neuropathy (P < 0.0001). The association between APS and CCCS was significant (P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%. CONCLUSION This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores.