Chetan Bhan

Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity.

Objective:Prospective randomized double-blind placebo-controlled crossover trial of 14 female patients (median age 52 [30–69] years) with proctographically defined evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity (elevated thresholds to balloon distension in comparison with age- and sex-matched controls). Background:Sacral nerve stimulation (SNS) is an evolving treatment for constipation. However, variable outcomes might be improved by better patient selection. Evidence that the effect of SNS may be mediated by modulation of afferent signaling promotes a role in patients with ED associated with rectal hyposensation. Methods:SNS was performed by the standard 2-stage technique (temporary then permanent implantation). During a 4-week period of temporary stimulation, patients were randomized ON-OFF/OFF-ON for two 2-week periods. Before insertion (PRE), and during each crossover period, primary (rectal sensory thresholds) and secondary (bowel diaries, constipation, and GIQoL [gastrointestinal quality of life] scores) outcome variables were blindly assessed. Results:Thirteen patients completed the trial. Following stimulation, defecatory desire volumes to rectal balloon distension were normalized in 10 of 13 patients (PRE: mean 277 mL [234–320] vs ON: 163 mL [133–193] vs OFF: 220 mL [183–257 mL]; P = 0.006) and maximum tolerable volume in 9 of 13 (PRE: mean 350 mL [323–377] vs ON: 262 mL [219–305] vs OFF: 298 mL [256–340 mL]; P = 0.012). There was a significant increase in the percentage of successful bowel movements (PRE: median 43% [0–100] vs ON: 89% [11–100] vs OFF: 83% [11–100]; P = 0.007) and Wexner constipation scores improved (PRE: median 19 [9–26] vs ON: 10 [6–27] vs OFF: 13 [5–29]; P = 0.01). There were no significant changes in disease-specific or generic quality of life measures. Eleven patients progressed to permanent stimulation (9/11 success at 19 months). Conclusions:Most patients with chronic constipation secondary to ED with rectal hyposensitivity responded to temporary SNS. The physiological results presented support a mechanistic role for rectal afferent modulation.

The effects of age and childbirth on anal sphincter function and morphology in 999 symptomatic female patients with colorectal dysfunction.

BACKGROUND AND OBJECTIVES: Conflicting data exist on the contributions of advancing age and childbirth on the structure and function of the anal sphincter. This study aimed to examine the relative contributions of age and childbirth in a large cohort of women referred for investigation of symptoms of colorectal dysfunction (fecal incontinence and constipation). SETTING: This study was conducted at a specialist surgical colorectal investigation unit in a university teaching hospital. PATIENTS: Retrospective analysis was performed on prospectively collected demographic, symptom profile, and physiologic data from 3686 female patients. Strict exclusion criteria were applied, leaving 999 patients for univariate, multivariate, and logistic statistical modeling. MAIN OUTCOME MEASURES: The effects of independent variables alone and in combination on anal sphincter pressures (resting and squeeze increment) and the presence of sphincter defects (internal and external) were expressed as regression coefficients and odds ratios. RESULTS: Median age was 42 years (range, 16–88), and parity was 2 (range, 0–11); 16% were nulliparous. Three hundred sixty patients had fecal incontinence, 352 had constipation, and 287 had combined symptoms. Anal resting tone decreased with age by 0.66 cm H2O per year, and by 4.3 cm H2O per birth, and was associated with both internal and external anal sphincter defects (p = 0.0001 for both). Squeeze increment pressures decreased by 0.3 cm H2O per year, and by 3.8 cm H2O per birth; decreased pressures were, however, only significantly associated with external anal sphincter defects (p = 0.0001) as a result of childbirth. Cesarean delivery was protective against both reduced anal pressures and sphincter defects. Pudendal nerve terminal motor latencies increased bilaterally with age and with vaginal delivery; the impact of both was greater on the left nerve. Rectal sensation was unaffected by age or parity. CONCLUSIONS: Aging predominantly affects anal resting pressures; childbirth, particularly instrumental delivery, is detrimental to the structure and function of the external sphincter.

Evacuation proctography: a reappraisal of normal variability

Interpretation of evacuation proctography (EP) images is reliant on robust normative data. Previous studies of EP in asymptomatic subjects have been methodologically limited. The aim of this study was to provide parameters of normality for both genders using EP.

Fecal incontinence in men: coexistent constipation and impact of rectal hyposensitivity.

BACKGROUND: The pathophysiology of fecal incontinence in men is poorly established. OBJECTIVE: The aim of this study was to assess the coexistence of constipation and determine the impact of rectal sensorimotor dysfunction in males with fecal incontinence. SETTING: This study was conducted at a tertiary referral center. PATIENTS: Included were adult male patients referred for the investigation of fecal incontinence over a 5-year period who underwent full anorectal physiology testing and completed a standardized symptom questionnaire. INTERVENTION: Standardized symptom questionnaires were fully completed, and anorectal physiologic test results (including evacuation proctography) were evaluated. MAIN OUTCOME MEASURES: The primary outcomes measured were the frequency of symptoms of associated constipation, the association of blunted rectal sensation (rectal hyposensitivity) with symptoms, and other physiologic measures. RESULTS: One hundred sixty patients met the inclusion criteria, and 47% of these patients described concurrent constipation. Fifty-four patients (34%) had sphincter dysfunction on manometry, only 19 of whom had structural abnormalities on ultrasound. Overall, 28 patients (18%) had rectal sensory dysfunction, 26 (93%) of whom had rectal hyposensitivity. Patients with rectal hyposensitivity were more likely to subjectively report constipation (77%) in comparison with patients with normal rectal sensation (44%; p = 0.001), allied with decreased bowel frequency (19% vs 2%; p = 0.003) and a sense of difficulty evacuating stool (27% vs 8%; p = 0.008). Cleveland Clinic constipation scores were higher in patients with rectal hyposensitivity (median score, 13 (interquartile range: 8–17) vs normosensate, 9 (5–13); p = 0.004). On proctography, a higher proportion of patients with rectal hyposensitivity had protracted defecation (>180 s; 35% vs 10%; p = 0.024) and incomplete rectal evacuation (<55% of barium neostool expelled, 50% vs 20%; p = 0.02). LIMITATIONS: This study was limited by the retrospective analysis of prospectively collected data. CONCLUSIONS: Only one-third of incontinent men had sphincteric dysfunction. Other pathophysiologies must therefore be considered. Nearly half of patients reported concurrent constipation, and one-sixth had rectal hyposensitivity, which was associated with higher frequencies of both symptomatic and objective measures of rectal evacuatory dysfunction. In the majority of adult males, fecal incontinence may represent a secondary phenomenon.

A systematic review of the literature on the surgical management of recurrent rectal prolapse.

There are no available guidelines to support surgical decision‐making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence‐based treatment algorithm.

Heated IntraPEritoneal Chemotherapy (HIPEC) for Patients With Recurrent Ovarian Cancer A Systematic Literature Review

Background Despite advances in surgical oncology, most patients with primary ovarian cancer develop a recurrence that is associated with a poor prognosis. The aim of this review was to establish the impact of Heated IntraPEritoneal Chemotherapy (HIPEC) in the overall survival of patients with recurrent ovarian cancer. Methods A search of PubMed/MEDLINE databases was performed in February 2015 using the terms “recurrent ovarian cancer,” “cytoreductive surgery/cytoreduction,” and “heated/hyperthermic intraperitoneal chemotherapy.” Only English articles with available abstracts assessing the impact of HIPEC in patients with recurrent ovarian cancer were examined. The primary outcome measure was overall survival, whereas secondary outcomes included disease-free survival and HIPEC-related morbidity. Results Sixteen studies with 1168 patients were analyzed. Most studies were Level IV, with 4 studies graded as Level III and 1 Level II. Cisplatin was the main chemotherapeutic agent used, but variations were observed in the actual technique, temperature of perfusate, and duration of treatment. In patients undergoing cytoreductive surgery and HIPEC, the overall survival ranged between 26.7 and 35 months, with disease-free survival varying between 8.5 and 48 months. Heated IntraPEritoneal Chemotherapy seems to confer survival benefits to patients with recurrent disease, with a randomized controlled study reporting that the overall survival is doubled when cytoreductive surgery is compared with cytoreductive surgery and chemotherapy (13. 4 vs 26.7 months). Heated IntraPEritoneal Chemotherapy–related morbidity ranged between 13.6% and 100%, but it was mainly minor and not significantly different from that experienced by patients who only underwent cytoreduction. Conclusions Cytoreductive surgery and HIPEC seem to be associated with promising results in patients with recurrent ovarian cancer. Large international prospective studies are required to further quantify the true efficacy of HIPEC and identify the optimal treatment protocol for a maximum survival benefit.

The influence of obesity and body-mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review

The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection.

Establishing a regional enterocutaneous fistula service: The Royal London hospital experience

BACKGROUND The development of enterocutaneous fistula (ECF) is one of the most challenging complications encountered in colorectal surgery. Currently, only two supra-regional centres are nationally designated in the United Kingdom to treat ECF patients. The aim of this study was to assess clinical outcome measures following the implementation of an ECF service at The Royal London Hospital. METHODS All patients diagnosed with enterocutaneous fistula between December 2005 and November 2011 were recruited to the study. Clinical outcomes analysed included successful ECF closure, number of surgical procedures required for successful ECF closure, re-fistulation rates and morbidity/mortality data. RESULTS 41 patients (20 M:21 F) of median age 54 years (range, 16-81) were studied. Patients had undergone a median of 4 (range, 1-18) operations prior to referral. Eleven fistulas (27%) healed spontaneously. Of the remaining 30 patients, 5 (17%) died before surgery due to uncontrollable sepsis and 6 (20%) refused surgical intervention and were managed conservatively. Nineteen patients (63%) underwent definitive surgical repair requiring a median of 1 (range, 1-2) operations, with recurrent fistulation reported in 4 patients (21%). No intra-operative mortality was encountered. Two (11%) patients died postoperatively due to cardio-respiratory complications. CONCLUSIONS These data compare favourably with outcome measures reported by designated national centres, suggesting ECF patients can be safely managed closer to home in regional units that have the appropriate expertise. Nevertheless, management of this condition remains critically dependent upon a dedicated multidisciplinary team approach.

The diagnostic yield of preoperative staging computed tomography of the thorax in colorectal cancer patients without hepatic metastases.

Background National UK guidelines recommend preoperative computed tomography (CT) examination of the chest for all patients with colorectal cancer (CRC) as identification of thoracic metastatic disease may influence treatment plans. The diagnostic yield of this approach for patients without radiological evidence of hepatic metastases remains unclear. The aim of this study was to establish the impact upon treatment of chest CT examination for CRC patients without metastatic liver disease. Patients and methods All patients diagnosed with CRC without liver metastases disease between December 2006 and December 2013 in a single institution were identified from a prospectively recorded departmental database. Data collected included patient demographics, disease stage and chest CT findings. Results There were 358 CRC patients (183 male, 175 female, median age 70 years, range 24–96 years) without liver metastases. Colon cancer accounted for 68% of cases with 32% of patients diagnosed with rectal cancer. The majority of patients (n=292, 81.6%) had no evidence of thoracic pathology during the study period. Lung metastases were identified in five (1.4%) patients, one of them subsequently diagnosed with benign pulmonary nodule. In 61 (17.0%) patients the lung nodules were classified as intermediate with only three subsequently reclassified as pulmonary metastases (n=1) or primary lung cancer (n=2). Conclusion In the absence of liver metastases, CRC rarely spreads to the lung. Consequently, preoperative chest CT examination for patients without evidence of liver metastases may not be necessary in the majority of patients. Future studies are required to identify patients at high risk for pulmonary metastases who may benefit from this preoperative investigation.

Perforated duodenal diverticulae: importance for the surgeon and gastroenterologist.

We present the case of a 78-year-old woman who was admitted for an elective left hemicolectomy for diverticular disease. Two days following the elective procedure, bilious fluid was noted in her pelvic drain. The patient returned to theatre, where a perforated duodenal diverticulum was excised and the defect primarily repaired. The patient then developed a low output enterocutaneous fistula which was treated conservatively with nasojejunal feeding and resolved spontaneously.