Boon-Swee Ooi

Experience of 3711 stapled haemorrhoidectomy operations

Stapled haemorrhoidectomy has been routinely performed in the Department of Colorectal Surgery, Singapore General Hospital since 1999.

Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer.

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m2) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.

Tumor size is irrelevant in predicting malignant potential of carcinoid tumors of the rectum

Abstract. The malignant potential and prognosis of rectal carcinoids are said to be related to tumor size. Our study assessed if size could predict the malignant potential and hence its management. All patients in the Department of Colorectal Surgery, Singapore General Hospital, who underwent surgery for rectal carcinoid tumors between February 1991 and September 2000 were analyzed. Twenty patients (11 men), median age 48 years (range, 33–77 years) were studied. Median follow-up was 40 months (range, 5–120 months). The median tumor diameter was 2.5 cm (range, 0.1–5.0 cm). Eleven patients underwent radical resection and 9 patients had local resection for a presumed benign tumor. Morbidity was 15% and postoperative death was 5%. Overall median survival was 24 months (range, 5–120 months). One patient had an anterior resection for rectal adenocarcinoma but had an incidental 0.1-cm carcinoid tumor near the resection margin which on histology was found to have carcinoid tumor metastasis to 2 out of 12 lymph nodes. In conclusion, tumor size cannot predict malignant potential as even small tumors (<1 cm) can be malignant. Accurate preoperative staging with radical surgery may be required.

PPH03 stapled hemorrhoidopexy: our experience

BackgroundStapled hemorrhoidopexy is an established treatment for hemorrhoidal disease. We evaluated our experience with stapled hemorrhoidopexy using the new Procedure for Prolapse and Hemorrhoids (PPH03) Proximate HCS hemorrhoidal circular stapler (Ethicon Endo–Surgery).MethodsWe retrospectively reviewed clinical data for 238 patients who had undergone stapled hemorrhoidopexy in our department over a 2–month period. Patients were followed–up for a median of 3.5 weeks (range, 1–11 weeks) and were analyzed for complications and resolution of symptoms.ResultsThe hemorrhoids treated were third– and fourth–degree, as well as second degree (after failure of other therapies). Mean duration of surgery was 12.7 minutes (range, 5–20 minutes) and the majority of patients was treated with an ambulatory procedure. Most patients were discharged within 6 hours after surgery. On follow–up, 3.7% of patiets had minor complaints after surgery. Technically, the new PPH03 stapler device has a quickclose knob, which allows rapid opening and closing. The closed staple height of 0.75 mm increases staple line compression on tissue and key blood vessels, hence minimizing bleeding. Prior to this, stapled hemorrhoidopexy was done using the PPH01 device.ConclusionsStapled hemorrhoidopexy using the new PPH03 stapler is a safe, short and effective procedure in the management of hemorrhoids. It can be done in the ambulatory setting and patients have few postoperative complications.

Minilaparotomy left iliac fossa skin crease incision vs. midline incision for left–sided colorectal cancer

Abstract.BackgroundMidline laparotomies offer excellent exposure but are associated with increased postoperative pain and longer recovery. A minilaparotomy resection of leftsided colorectal cancers was studied as an alternative approach.Patients and methodsWe performed a case–control retrospective review of 280 randomly selected patients (140 midline incisions; 140 left skin crease incisions) who underwent elective, curative resection of left–sided colorectal cancers.ResultsPatients in both groups were of comparable age and sex. The left skin crease incision was shorter (median length, 13.5 cm) than the midline incision (median length, 20.0 cm). Median operation time was less in the left skin crease group (75 min) than in the midline incision group (105 min). Similar types of operations were performed, including left hemicolectomies, sigmoid colectomies, anterior resections and ultra–low anterior resections. Adequacy of resection was confirmed by histological analysis, with no involvement of margins. The median numbers of lymph nodes removed were comparable: 10 for the skin crease incision group and 12 for the midline incision group. Postoperative parameters for the skin crease incision group showed that feeding, ambulation, narcotic use and hospital stay were significantly better than the parameters in the midline group. Complications of intestinal obstruction were also reduced in the skin crease incision group.ConclusionsThe limited left skin crease incision provides adequate margins of clearance in colorectal cancers when compared to the midline incision, but has advantages of shorter operation time, earlier feeding and ambulation, and earlier discharge from hospital.

Prospective randomized crossover trial comparing fibre with lactulose in the treatment of idiopathic chronic constipation

AbstractBackgroundFibre is often recommended as the first-choice treatment but its effects can be uneven. The aim of the study was to compare the clinical efficacy and tolerability of fibre versus lactulose in outpatients with chronic constipation.MethodsIn a prospective randomized crossover trial, patients were randomized to receive fibre or lactulose for four weeks. Between treatments, patients had at least one week free of laxatives.Results50 patients, of median age 50 years (range, 18–85) were recruited and 39 patients completed the trial. Compared to fibre, lactulose resulted in significantly higher mean bowel frequency (7.3, 95% CI 5.7 to 8.9 vs. 5.5, 95% CI 4.4 to 6.5; p=0.001) and stool consistency score (3.4, 95% CI 3.1 to 3.7 vs. 2.9, 95% CI 2.5 to 3.3; p=0.018). Scores for ease of evacuation were similar. The frequencies of adverse effects were not significantly different, but greater in the lactulose group. Mean patients’ recorded improvement score was significantly higher after taking lactulose than fibre (6.2, 95% CI 5.5 to 7.0 vs. 4.8, 95% CI 4.0 to 5.9; p=0.017). Of the 39 patients who completed the trial, 24 (61.5%) preferred lactulose and 14 (35.9%) preferred fibre.Conclusions Lactulose had better efficacy than fibre for chronic constipation in ambulant patients, although both treatments were equally well tolerated in terms of adverse effects.

Phenotypic characteristics of hereditary non-polyposis colorectal cancer by the Amsterdam criteria: an Asian perspective.

Background:  Hereditary non‐polyposis colorectal cancer (HNPCC) is an autosomal disease with a 68–82% lifetime risk of colorectal cancer (CRC). This study examined the phenotypic characteristics of CRC in Amsterdam criteria‐positive Asian patients from the Singapore Polyposis Registry.

Stapled hemorrhoidopexy for prolapsed piles performed with concurrent perianal conditions.

those who had lateral anal sphincterotomy undertaken concurrently. Of the 3 patients with fistula in ano, two had simple low anal fistulas that were laid open. SH was performed with the anastomosis proximal to the internal opening of the fistula. One of these patients had postoperative bleeding from the stapler line, which resolved with submucosae adrenaline injection. The other patient was readmitted 5 days after discharge from hospital for persistent perianal pain. This patient was treated symptomatically with simple oral analgesics and was discharged the following day. The third patient had an atypical horseshoe type of fistula in ano, with external openings at 3 and 9 o’clock positions and an internal opening at the 12 o’clock position. These tracts were laid open. However, the patient continued to have pain and fever postoperatively. This was attributed to a collection of pus at the base of the scrotum. Re-operation was done to drain the abscess. On the whole, 5 of 44 patients (11.3%) developed minor complications of bleeding, pain and localized abscess in the immediate postoperative period. None of these 44 patients developed major complications. The median pain score was 6 (range, 2–10) on the same day after operation, and 1 (range, 0–4) 2–4 weeks after surgery. All patients were fully continent and pain-free 8–12 weeks following surgery. The median overall satisfaction was 9 (range, 7–10). Pain scores and overall satisfaction for each of the concomitant conditions are shown in Table 1. There was an increase in the immediate postoperative pain when another procedure was undertaken to treat the concurrent perianal conditions. In view of this, surgeons must be prepared to counsel patients pre-operatively regarding the increase in pain after surgery. Our small study showed that SH can be performed in the presence of concurrent perianal conditions with minimal complications. However, the severity of postoperative pain C O R R E S P O N D E N C E

Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey

Background:  This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre.

A prospective study assessing anal plug for containment of faecal soilage and incontinence

Objective  Faecal incontinence is a common and embarrassing problem for many individuals. Some patients remained symptomatic despite the availability of different treatments. There is a limited range of commercially available products designed to cope with faecal incontinence. The anal plug has been developed to contain the loss of stool. This study aimed to evaluate the use of anal plug in Asian patients with intractable faecal soilage and incontinence judged by clinical and functional outcomes.