F. Seow-Choen

Comparison of J-Pouch and Coloplasty Pouch for Low Rectal Cancers: A Randomized, Controlled Trial Investigating Functional Results and Comparative Anastomotic Leak Rates

ObjectiveTo assess the efficacy of a novel coloplasty colonic pouch design in optimizing bowel function after ultralow anterior resection. Summary Background DataA colonic J-pouch may reduce excessive stool frequency and incontinence after anterior resection, but at the risk of evacuation problems. Experimental surgery on pigs has suggested that a coloplasty pouch (CP) may be a useful alternative. Although CP has recently been shown to be feasible in patients, there is no randomized controlled trial comparing bowel function with the J-pouch. MethodsAfter anterior resection for cancer, patients were allocated to either J-pouch or CP-anal anastomoses. Continence scoring, anorectal manometry, and endoanal ultrasound assessments were made before surgery. All complications were recorded, and these preoperative assessments were repeated at 4 months. The assessments were repeated again at 1 year, and a quality of life questionnaire was added. ResultsEighty-eight patients were recruited from October 1998 to April 2000. Both groups were well matched for age, gender, staging, adjuvant therapy, and mean follow-up. There were no differences in the intraoperative time and hospital stay. CP resulted in more anastomotic leaks. At 4 months, J-pouch patients had 10.3% less stool fragmentation but poorer stool deferment and more nocturnal leakage. However, there were no differences in the bowel function, continence score, and quality of life at 1 year. There were no differences in the anorectal manometry and endoanal ultrasound findings. ConclusionsColoplasty pouches resulted in more anastomotic leaks and minimal differences in bowel function. At present, the J-pouch remains the benchmark for routine clinical practice, and due care (including defunctioning stoma) should be exercised in situations requiring CP.

A simple and effective treatment for hemorrhagic radiation proctitis using formalin

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were Treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42–73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9–46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1–12 months). The median number of units of blood transfused previously per patient was four (range, 2–32). The time taken for formalin therapy was 20 minutes (range, 10–70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1–6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.

Lymph node involvement and tumor depth in rectal cancers: An analysis of 805 patients

BACKGROUND: Superficial rectal tumors are said to involve regional lymph nodes rarely. This presumption must be proven beyond any doubt if less radical surgery is to be offered for such patients. PATIENTS AND METHODS: Eight hundred five cases (467 males; median age, 64 (range, 19–97) years) of rectal cancer were reviewed. RESULTS: Lymph node positivity, number of lymph nodes involved, lymphatic vessel, and venous and perineural invasion were significantly increased with increasing depth of invasion of tumor through the bowel wall in univariate analysis. The percentage of lymph node involvement at each tumor depth was as follows: T1, 5.7 percent; T2, 19.6 percent; T3, 65.7 percent; T4, 78.8 percent. Overall lymph node involvement was 59 percent. For patients younger than 45 years of age, the percentage of lymph node involvement was 33.3, 30, 69.3, and 83.3 percent compared with 3.1, 8.4, 64.2, and 78.8 percent for patients aged 45 years or above for T1, T2, T3, and T4, respectively. CONCLUSION: Increased depths of tumor penetration beyond T1 and age less than 45 years have an excessive incidence of lymph node positivity. The finding of lymphatic vessel invasion on biopsy is highly indicative of lymph node metastasis.

Early postoperative results of a prospective series of laparoscopic vs. open anterior resections for rectosigmoid cancers

PURPOSE: This study was undertaken to compare postoperatively laparoscopic (LAR) with open (OAR) anterior resection in patients with rectosigmoid cancers. METHODS: Forty consecutive patients were divided into two groups: 20 patients (9 males) were allocated to LAR and 20 patients (6 males) to OAR. RESULTS: Median age in the LAR group was 62 (range, 39–77) years, and in the OAR group, it was 61 (range, 43–84) years (P=0.9). Median lengths of the distal margin of clearance beyond the tumor were 4 (range, 2–8) cm and 4.5 (range, 3–7.5) cm in the LAR and OAR groups, respectively (P=0.35). Median numbers of lymph nodes harvested were 20 (range, 7–49) and 19 (range, 7–97) for the LAR and OAR groups, respectively (P=0.44). Median operating times were 90 (range, 55–185) minutes and 73 (range, 40–140) minutes in the LAR and OAR groups, respectively (P=0.08). Blood losses were 50 (range, 50–800) ml and 50 (range, 50–1,500) ml in the LAR and OAR groups, respectively. There was no intraoperative complication in either group, and no laparoscopic patient was converted to an open procedure. Median length of extraction site incision in the LAR group was 5.5 (4–13) cm, and length of incision in the OAR group was 18 (8–25) cm (P<0.002). CONCLUSION: There were no significant differences between the two groups with regard to duration of parenteral analgesia, starting of fluid and solid diet after surgery, or time to first bowel movement and time to discharge from the hospital.

Transanal approach to rectocele repair may compromise anal sphincter pressures

PURPOSE: This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation. METHOD: Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later. RESULTS: All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n=19; after, n=3;P=0.001), need to digitate per vagina (before, n=16; after, n=0;P=0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2);P=0.004), and laxative requirements (before, n=7; after, n=0;P=0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P<0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P<0.05) after operations. There was no other morbidity. CONCLUSION: Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.

Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial.

The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 ± 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 ± 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 ± 2.8 vs. 49 ± 1.4/week; p<0.05) and less soiling at passing flatus (38% vs. 73.7%; p<0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 ± 0.4 vs. 8 ± 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p<0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch. Après résection antérieure du rectum ultra-basse, le réservoir colique en J (POUCH) fonctionne mieux que l’anastomose coloanale sans réservoir (STRAIGHT), mais il existe peu d’études avec un suivi à long terme. Cette étude randomisée, contrôlée, compare l’évolution fonctionnelle et la manométrie anale ainsi que l’évaluation barostatique dans ces deux groupes de patients pendant une période de deux ans. Quarante-deux patients consécutifs ont été inclus, dont 19 STRAIGHT (17 hommes; âge moyen 62,1 (ETS: 2,3) ans) et 16 POUCH (11 hommes; âge moyen 61,3 (3,2) ans). Quatre patients sont décédés de métastases (et deux ont émigré), mais il n’y avait aucune morbidité ou de récidive locale. A 6 mois, les patients POUCH allaient significativement moins fréquemment à la selle (32,9) (2,8) vs. 49 (l,4)/semaine; p<0,05) et avaient moins de souillures lorsqu’ils passaient des gaz (38% vs. 73,7%; p<0,05). A 2 ans, les résultats des deux groupes se sont améliorés avec aucune différence en ce qui concernait la fréquence des selles (7,3 (0,4) vs. 8 (0,2)/semaine) ou la souillure en passant des gaz (38% vs. 53%). Les problémes de défécation sont restés minimes dans les deux groupes. Les pressions de contraction anale étaient significativement perturbées dans les deux groupes, jusqu’à deux ans (p<0,05). Le volume rectal maximal tolérable et la compliance n’étaient pas significativement différents entre les deux groupes. Selon les résultats de la barostatique phasique on a mis en évidence une perturbation à 6 mois mais avec une récupération à 2 ans, suggerérant que la récupération postopératoire de nerfs sympathiques afférents joue peut-être un rôle dans la récupération fonctionnelle. En conclusion, à 6 mois, la fréquence des selles et de l’incontinence sont moindres après une anastomose POUCH, mais après 2 ans, les patients ayant une anastomose STRAIGHT ont des résultats similaires. Néanmoins, cet avantage fonctionnel inhérent à l’utilisation de l’anastomose avec réservoir en J ne demande qu’un minime effort de plus et l’intervention se complique peu. Existen pocos trabajos que valoren los resultados funcionales tardíos de la bolsa en J de colon (POUCH) con la anastomosis termino-terminal colorrectal, tras resecciones anteriores, muy bajas, de recto. En este estudio controlado y randomizado, se comparan, tras un seguimiento de 2 años, los resultados funcionales, la manometría anal y la barestesia rectal en dos grupos de pacientes tratados quirúrgicamente, con una de las dos técnicas mencionadas. La población estudiada comprende 42 pacientes; 19 tratados mediante anastomosis directa (grupo STRAIGHT) de los que 17 fueron hombres con una edad media de 62.1 (SEM: 2.3) años; el otro grupo (POUCH) comprende 16 pacientes de los que 11 fueron hombres con edad media de 61.3 (3.2) años. 4 enfermos murieron como consecuencia de diseminación metastásica y 2 emigraron. No se registró morbilidad quirúrgica alguna, ni recidivas locales. A los 6 meses, los enfermos del grupo POUCH presentaban un número significativamente menor de deposiciones [32.9 (2.8) vs. 49 (1.4)] por semana (p<0.05). y al ventosear dejan escapar menos materia fecal (38% vs 73.7%; p<0.05). A los 2 años, los pacientes de ambos grupos mejoraron sin que existieran diferencias ni en el número de deposiciones [7.3 (0.4) vs. 8 (0.2)], ni al mancharse al ventosear (38% vs. 53%). Los problemas de defecación fueron mÍnimos en ambos grupos. Las presiones anales al intento de defecar mejoraron significativamente en ambos grupos, a partir de los 2 años de la intervención (p<0.05). El volumen máximo tolerable y la “compliance” rectal fue igual en los dos grupos. La sensibilidad rectal, detectada mediante un programa fásico barestésico, mejora a los 6 meses y se recupera a los 2 años de la operación, lo que sugiere que en la recuperacion postoperatoria, los nervios simpáticos aferentes no resecados, desempeñar un importante papel en la recuperación funcional. Conclusión: el número de defecaciones y la incontinencia son menores en el grupo POUCH, hasta que transcurren 6 meses de la operación, pero tras un période de adaptación de 2 años, los resultados en el grupo POUCH y en el grupo STRAIGHT son semejantes. A pesar de ello la recuperción funcional es más rápida con la bolsa en J de colon (POUCH) y este mayor confort para los enfermos se puede alcanzar con un minimo esfuerzo añadido y sin complicaciones.

Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure.

PURPOSE: This study was designed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure. METHODS: Forty patients with chronic anal fissure were prospectively studied. Patients randomized to the sphincterotomy group (n=20; median age, 34 (range, 16–61) years) underwent lateral internal anal sphincterotomy. Patients randomized to the flap group (n=20; median age, 32 (range, 20–44) years) had an anal advancement flap. RESULTS: All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group (P= 0.12). No patient in either group was incontinent to any degree following surgery. Patient satisfaction with surgery was similar in both groups. CONCLUSION: Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure.

Anal sphincter injuries from stapling instruments introduced transanally

PURPOSE: Injury sustained from the transanally introduced stapling technique was assessed by comparison with biofragmentable anastomotic ring anastomosis, which excluded anal manipulation. METHODS: A randomized, controlled trial was conducted on consecutive patients undergoing sigmoid colectomy (where pelvic nerve injury was avoided). A bowel function questionnaire was administered six months after surgery. Anorectal manometry and endoanal ultrasonography were performed preoperatively and at six months postoperatively. The observers were blinded to the randomization. RESULTS: There were 18 patients in the transanally introduced stapling technique group and 17 patients in the biofragmentable anastomotic ring group, with no differences in age, gender, Dukes staging, and follow-up. Three of the transanally introduced stapling technique patients had occasional liquid soiling, which was absent in biofragmentable anastomotic ring patients. Mean change in resting anal pressures was also significantly impaired when compared with patients with biofragmentable anastomotic ring (P=0.007). Endosonographic internal sphincter fragmentation was found in five transanally introduced stapling technique patients but none after biofragmentable anastomotic ring anastomosis (P=0.046). Internal sphincter fragmentation was associated with the impaired resting pressures (P=0.007). External sphincter deficiencies were found after transanally introduced stapling technique in two patients (biofragmentable anastomotic ring = 0), and these were associated with the soiling (P=0.005). CONCLUSIONS: The transanally introduced stapling technique may result in anal sphincter defects and impaired anal pressures when assessed at six months of follow-up.

Prospective, randomized trial comparing pain and clinical function after conventional scissors excision/ligation vs. diathermy excision without ligation for symptomatic prolapsed hemorrhoids

Forty-nine consecutive patients with symptomatic prolapsed hemorrhoids were prospectively randomized for conventional scissors excision with ligation (Group A; n = 16) or diathermy excision without ligation (Group B; n = 33). The median time taken to complete the procedure was 20 minutes (range, 10–40 minutes) and 10 minutes (range, 5–35 minutes) in Groups A and B, respectively (P<0.05). Length of hospital stay was similar in both groups, with a median of three days and a range of two to five days. The median length of follow-up was 35 weeks (range, 20–50 weeks) and 35 weeks (range, 20–51 weeks) for Groups A and B, respectively. There was no statistical difference in the severity of postoperative pain between the two groups. The use of postoperative oral analgesics was significantly lower in Group B (P<0.02), but there was no significant difference in the demand for intramuscular or topical analgesics. Diathermy excision of hemorrhoids is significantly faster than scissors excision, there is less bleeding, the vascular pedicles need not be ligated, and there is significant reduction in the requirement for oral analgesics postoperatively without any increase in early or late postoperative complications.

A Randomized Controlled Trial of 0.5% Ferric Hyaluronate Gel (Intergel) in the Prevention of Adhesions Following Abdominal Surgery

Introduction:Intestinal adhesion following abdominal surgery is a significant sequela to abdominal surgery. Intergel is a hyaluronate-based gel that reduces the incidence of postoperative adhesions when added to the peritoneal cavity before closure in gynecologic surgery. This is a randomized controlled trial evaluating the efficacy and safety of Intergel in colorectal resections. Although the study aimed to recruit 200 patients based on power analysis, recruitment was suspended because of the high morbidity in the treatment group. Methods:A total of 32 patients were randomized to either Intergel treatment (treatment group) or no treatment (control group) following open abdominal surgery. Primary endpoints included the incidence of adhesive obstruction, the need for subsequent adhesiolysis, and the incidence of wound and anastomotic complications. A secondary endpoint involved quality-of-life assessment. Results:Seventeen patients were randomized to the treatment group and 15 to the control group. All patients, except 1 in the treatment group, underwent resection and anastomosis of the colon or rectum for benign or malignant disease. A significant difference was observed in the number of patients with postoperative morbidities between the 2 groups (65% treatment group versus 27% control group, P = 0.031). There was a high rate of anastomotic dehiscence (5 treatment group versus 1 control group, P = 0.178) and prolonged postoperative ileus (10 treatment group versus 2 control group, P = 0.011) observed in treatment group. One case of peritonitis occurred in the treatment group in the presence of an intact anastomosis. Wound complications were more common in treatment group but failed to reach statistical significance. Conclusion:The use of Intergel in abdominal surgery where the gastrointestinal tract is opened leads to unacceptably high rates of postoperative complications.