Dorin Ziyaie

Photodynamic therapy is associated with an improvement in survival in patients with irresectable hilar cholangiocarcinoma

BACKGROUND The majority of patients with hilar cholangiocarcinoma have irresectable disease and require palliation with biliary stenting to alleviate symptoms and prevent biliary sepsis. Chemotherapy and radiotherapy have proved ineffective, but recent studies suggest photodynamic therapy (PDT) may improve the outlook for these patients. This prospective clinical cohort study has evaluated the efficacy of radical curative surgery, standard palliative therapy (stent +/- chemotherapy) and a novel palliative therapy (stent +/- Photofrin-PDT) in 50 consecutive patients treated for hilar cholangiocarcinoma over a 5-year period. METHODS Between January 2002 and December 2006, 50 patients with hilar cholangiocarcinoma were evaluated for treatment. Ten patients were considered suitable for curative resection (Cohort 1). Forty patients with irresectable disease were stratified into Cohort 2 - Stent +/- chemotherapy (n= 17); and Cohort 3 - Stent +/- PDT (n= 23). Prospective follow-up in all patients and data collected for morbidity, mortality and overall patient survival. RESULTS The median age was 68 years [range 44-83]. Positive cytology/histology was obtained in 28/50 (56%). One death in Cohort 1 occurred at 145 days after surgical resection. No treatment related-deaths occurred in Cohort 2 or 3, chemotherapy-induced morbidity in three patients in cohort 2, PDT-induced morbidity in 11 patients in cohort 3. Actual 1-year survival was 80%, 12% and 75% in Cohorts 1, 2 and 3, respectively. Mean survival after resection was 1278 days (median survival not reached). Mean and median survival was 173 and 169 days, respectively, in Cohort 2; and 512 and 425 days in Cohort 3. Patient survival was significantly longer in cohorts 1 and 3 (P < 0.0001; Log rank test). CONCLUSION This prospective clinical cohort study has demonstrated that radical surgery and palliative Photofrin-PDT are associated with an increased survival in patients with hilar cholangiocarcinoma.

A prospective multicentre observational study of Permacol™ collagen paste for anorectal fistula: preliminary results

Permacol™ collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial.

Final results of a European, multi-centre, prospective, observational Study of Permacol™ collagen paste injection for the treatment of anal fistula

Permacol™ collagen paste (Permacol™ paste) is an acellular cross‐linked porcine dermal collagen matrix suspension for use in soft‐tissue repair. The use of Permacol™ paste in the filling of anorectal fistula tract is a new sphincter‐preserving method for fistula repair. The MASERATI100 study was a prospective, observational clinical study with the objective to assess the efficacy of Permacol™ collagen paste for anal fistula repair in 100 patients.

Lumbosacral discitis following laparoscopic ventral mesh rectopexy: a rare but potentially serious complication

Laparoscopic ventral mesh rectopexy (LVMR) has widely become accepted as one of the most frequently used techniques in the treatment of full thickness rectal prolapse and increasingly for obstructive defaecation syndrome (ODS) [1–3]. Mesh is placed between the rectum and the vagina and secured with suture material to the ventral rectum and suspended from the sacral promontory using suture material or titanium tacks/screws, to ensure secure and sustainable anchorage. Whether to use synthetic or biological mesh has been the subject of recent controversy [4]. Whilst synthetic mesh is assumed to have a more durable longevity, erosion and infection have been perceived to occur more frequently and critics are in favour of biological alternatives. Recently [5], what type of suture material should be used to secure the mesh to the rectum has also been discussed; however, very little thought has been given to the mode in which mesh is suspended from the sacral promontory. Here, we present a rare but serious complication that directly resulted from the use of titanium screws for the fixation of mesh to the promontory. We believe that whilst this complication remains rare, awareness of it should be raised amongst the surgical community since early recognition and immediate treatment are the crucial steps in reducing the subsequent morbidity. Case report

Extramammary Paget disease of the perianal region: the potential role of imiquimod in achieving disease control

Extramammary Paget disease (EMPD) is a rare perineal neoplasia associated with a high rate of local recurrence. Surgical excision is the standard treatment; however, this has high rates of post-operative morbidity in combination with potentially mutilating results. Previous literature has demonstrated good response with imiquimod 5% cream in patients with vulval EMPD, yet its effectiveness in primary perianal disease is unknown. We describe the case of a 40-year-old woman presenting with EMPD of the perianal region, providing detailed histological and pictoral evidence of its response to topical imiquimod 5% cream over a 16-week period, which initially resulted in remission prior to metastatic lymph node recurrence. This case demonstrates the potential for topical imiquimod cream to avoid major surgery and its associated complications in patients presenting with EMPD of the perianal region. We discuss the current evidence for treating this rare condition with medical therapy, how this case adds to current literature and possible future directions.

Laparoscopic assisted colonoscopy: results and follow up endoscopic success.

Incomplete colonoscopy occurs in 8–10% of attempted examinations. An incomplete colonoscopy is usually followed by radiological evaluation of the large bowel to complete the colonic assessment. Patients then found to have polyps of > 1 cm represent a significant management dilemma. This study describes our experience using laparoscopy to facilitate complete colonoscopy and polypectomy in patients with fixed angulation and the success of subsequent colonoscopies.

PWE-304 How accurate is pre-operative staging of the pelvic lymph nodes by MRI and ct in rectal cancers requiring abdomino-perineal resection

Introduction MRI has proven extremely useful in pre-operative staging of rectal cancer. It has replaced CT scanning in assessment of the pelvis to become the current basis for Multi-Disciplinary Team discussion and decision making in relation to neoadjuvant therapy. However, recent studies correlating MRI and histopathology results for all rectal cancers have found a poorer performance for MRI in low rectal cancers. This study aimed to assess and compare the performance of CT and MRI scanning in assessing lymph node positivity in rectal cancers requiring abdomino-perineal excision of rectum (APER). Method All patients who underwent APER operations for rectal cancer in one NHS trust between Jan 2004 and Nov 2014 were identified from a pathology database. This covered the period in which MRI gradually replaced CT scanning in staging the pelvis. Exclusion criteria were benign disease, cancers other than adenocarcinoma and absence of CT or MRI scan preoperatively or where lymph node status was not reported. Pathological TNM staging was used to assess regional lymph node (LN) involvement. These findings were compared with those reported on CT and/or MRI scan. Results 150 patients fulfilled the criteria. 132 patients had pre-operative CT scan assessment of lymph node status. 58 patients had pre-operative MRI scan assessment. 48 patients had both a CT and an MRI scan pre-operatively. Table 1shows the comparison of reported lymph node stage by histopathological assessment of the specimen and CT/MRI.Abstract PWE-304 Table 1 LN +ve on pathology LN -ve on pathology LN +ve on CT 23 16 LN -ve on CT 35 58 LN +ve on MRI 15 24 LN –ve on MRI 6 13 In terms of identifying LN positivity, CT achieved a sensitivity of 39% with a specificity of 78% while MRI achieved a sensitivity of 71% with a specificity of 35%. Conclusion The specificity of MRI in this cohort of patients undergoing APER suggests that decisions based on LN positivity will risk significant overtreatment. Although CT was considerably less sensitive it was more specific. As MRI was gradually replacing CT, data were available for comparison but not from identical time periods. There were also a number of radiologists involved in reporting both the CT and MRI scans. However, these data do suggest that in routine practice, pre-operative imaging of low rectal cancer by CT will under-estimate LN involvement while reliance on MRI will over-estimate LN involvement. Disclosure of interest None Declared.

OC-094 Interim results of a european, multi-centre, prospective, observational study of permacol™ collagen paste injection for the treatment of anal fistulas

Introduction Historically, the treatment of anal fistulas has required a compromise between successful fistula healing and preservation of continence. The aim of this study (NCT01624350) is to evaluate clinical outcomes of anal fistulas treated with Permacol™ collagen paste. Method Patients (N = 98) with magnetic resonance imaging-confirmed intersphincteric or transsphincteric anal fistulas, cryptoglandular primary or recurrent, from ten European sites were treated with Permacol™ collagen paste. Fistula healing, adverse events, and patient satisfaction were assessed up to 12 months post-surgery, with fistula healing at 6 months confirmed by clinical assessment as the primary endpoint. Cox regression analyses were performed to determine if patient or fistula characteristics correlate with better healing. Results The median follow-up was 26.8 weeks (range 0.1–62.4 weeks), with 87 and 46 patients having healing data at 6 months and 12 months, respectively. At 6 months follow-up, 51 (58.6%) patients exhibited a clinically-healed anal fistula, including 20/35 (57.1%) that were recurrent at the time of treatment. At 12 months, 19 (41.3%) patients were healed. Younger patients and those with evidence of expulsion or leakage of Permacol™ collagen paste were the only variables associated with a significantly increased risk of failure (p = 0.0017 and p = 0.0068, respectively). A total of six serious adverse events were reported, four of which (perianal abscess, n = 2; non-healing fistula tract, n = 1; complex regional pain syndrome, n = 1) were possibly related to the device and/or the procedure. Continence was preserved throughout the follow-up. At their last visit, over 70% of patients reported being satisfied or very satisfied with their operation, indicating that some patients were satisfied even though their fistula did not heal. Conclusion These preliminary results demonstrate that Permacol™ collagen paste is a well-tolerated, sphincter-sparing technique for the treatment of anal fistulas with low morbidity. Disclosure of interest P. Giordano Grant/Research Support from: Covidien, Consultant for: Covidien, Speaker Bureau of: Covidien, P. Sileri Grant/Research Support from: Covidien, S. Buntzen Grant/Research Support from: Covidien, Speaker Bureau of: Medtronic, A. Stuto Grant/Research Support from: Covidien, J. Nunoo-Mensah Grant/Research Support from: Covidien, L. Lenisa Grant/Research Support from: Covidien, B. Singh Grant/Research Support from: Covidien, Speaker Bureau of: Covidien, O. Thorlacius-Ussing Grant/Research Support from: Covidien, B. Griffiths Grant/Research Support from: Covidien, D. Ziyaie Grant/Research Support from: Covidien, Speaker Bureau of: Covidien.