Graham L. Newstead

Anal fistula: Levovist®-enhanced endoanal ultrasound: A pilot study

AbstractPURPOSE: The aim of the study was to investigate the usefulness of the contrast agent Levovist® in ultrasound assessment of anal fistula. METHODS: Fifteen patients (11 females, mean age 46) with a diagnosis of anal fistula were assessed by physical examination, conventional ultrasound, Levovist®-enhanced ultrasound, and surgery. Levovist® was injected via a cannula into the fistula. The results of physical examination, conventional ultrasound and Levovist®-enhanced ultrasound were compared with surgical findings as criterion standard. RESULTS: At physical examination, three intersphincteric fistulas and two sinuses were diagnosed. Using conventional ultrasound, five intersphincteric and five transsphincteric fistulas were found; four fistulas and one sinus were not detected. Levovist®-enhanced ultrasound revealed one sinus, five intersphincteric, seven transsphincteric, and one extrasphincteric fistulas; only one fistula was not detected. At surgery, three intersphincteric, seven transsphincteric, and two sinuses were found; however, the extrasphincteric fistula detected by Levovist® was missed. Compared with physical examination, Levovist®-enhanced ultrasound and surgery were significantly favorable in the diagnosis of anal fistula (P < 0.05 in chi-squared test and Fisher’s exact probability test). The concordance rate of surgery with conventional ultrasound was 69 percent (9/13) and with Levovist®-enhanced ultrasound was 77 percent (10/13). However, because the extrasphincteric fistula was missed at surgery, the accuracy of Levovist®-enhanced ultrasound was in fact 85 percent (11/13) if surgical finding was not used as the standard. The internal opening was detected at physical examination in 2 patients (13 percent), with conventional ultrasound in 4 patients (27 percent), with Levovist®-enhanced ultrasound in 9 patients (60 percent) and during surgery in 11 patients (85 percent). Consistently, Levovist®-enhanced ultrasound and surgery were significantly better than physical examination in the diagnosis of internal opening (P < 0.05). One secondary extension and two sphincter defects were detected by both types of ultrasound. The extension was not confirmed during surgery. No patients developed recurrence or nonhealing of wound. One patient developed incontinence to flatus and one developed a perianal hematoma. CONCLUSION: Levovist®-enhanced ultrasound is better at assessing anal fistula than physical examination and conventional ultrasound. However, a future trial comparing Levovist®, hydrogen peroxide, and magnetic resonance imaging is needed to establish which is the most cost-effective preoperative imaging technique to use.

Diverticulectomy is inadequate treatment for short Meckel's diverticulum with heterotopic mucosa.

Background:  Meckels diverticulum is a vestigial remnant of the vitellointestinal duct that may occasionally contain heterotopic gastric mucosa thought to arise from residual yolk sac cells. This may cause significant rectal bleeding, the source of which may be difficult to identify. The present paper addresses the question of whether the choice of resection technique should depend on the macroscopic appearance of the Meckels diverticulum.

Short-Term and Long-Term Results of Combined Sclerotherapy and Rubber Band Ligation of Hemorrhoids and Mucosal Prolapse

AbstractPURPOSE: Rubber band ligation is a common office procedure for symptomatic hemorrhoids. The aim of the study was to assess our short-term and long-term results of combined sclerotherapy and rubber band ligation in the management of hemorrhoids and incomplete mucosal prolapse. METHODS: Data on 6,739 patients who had previous combined sclerotherapy and rubber band ligation by the senior authors (GLN and PRD) were retrieved from the database dating between January 1976 and June 2000. These patients either had hemorrhoids or incomplete mucosal prolapse. Furthermore, questionnaires were sent to a random sample of 2,400 patients. Telephone interviews were performed for 600 of the nonrespondents. RESULTS: Of 6,739 patients (3,683 males; mean age, 46.7 years) in the database, 4,686 (70 percent) received the procedure once, and 2,053 (30 percent) received the procedure more than once. There were 5,689 patients (84 percent) who had their procedures performed consecutively within a planned period, and only 1,050 patients (16 percent) had repeat procedures after a period of more than 12 months from their last treatments. Thus, the recurrence rate was 16 percent. The overall complication rate was 3.1 percent, with minor bleeding being the major complaint. With regard to the questionnaire, 44 percent responded. The mean follow-up period was 6.5 (range, 1–11) years. There were patients who had residual symptoms of bleeding (19 percent), itch (21 percent), and lump (20 percent). However, 58 percent of patients who replied were asymptomatic. With satisfaction scores ranging from +3 to −3 (+3 indicating complete satisfaction and −3 indicating complete dissatisfaction), 90 percent scored ≥1, 9 percent scored 0 or less, and 1 percent did not specify a score. Hemorrhoidectomy was required in 7.7 percent of the responders. Of 600 phone interviews with the nonrespondents, 152 responded to the questionnaires. Although there was less satisfaction from the phone respondents, which may have accounted for the initial nonresponse, no statistical difference was detected in residual symptoms. CONCLUSIONS: Combined triple sclerotherapy and rubber band ligation is an effective treatment for early hemorrhoids and incomplete mucosal prolapse, with low rates of recurrence, complications, and hemorrhoidectomy, and it can be repeated easily.

Achieving quality in colonoscopy: bowel preparation timing and colon cleanliness

Background:  Colonoscopy is considered the gold standard for investigation of large bowel pathology. Numerous factors influence the efficacy of bowel preparation for colonoscopy. Inadequate bowel preparation can lead to missed pathology. Timing of fasting and bowel preparation, timing of procedure and possibly patient bowel habit and presence of diverticula may have an influence on the quality of the preparation. The aim of this study was to investigate the quality of cleansing of sodium picosulfate (Picoprep‐3™, Pharmatel Fresenius Kabi Pty Ltd, Pymble, NSW, Australia) with different administration schedules and to evaluate whether patients bowel patterns influence the quality of cleansing.

Functional outcome and quality of life after ileal pouch−anal anastomosis in children and adults

Background:  In the past, children with ulcerative colitis were treated with a total colectomy, ileostomy and mucous fistula; ileal pouch−anal anastomosis was postponed until adulthood. The aim of the present study was to assess the functional outcome and quality of life after ileal pouch−anal anastomosis and determine whether it is justified to perform the operation in children when surgery is indicated.

Cholecystectomy in patients with Crohn's ileitis.

AbstractPURPOSE: Gallstone disease is reported to be higher in patients with Crohn’s disease than in the general population. This study was designed to determine the prevalence of cholecystectomy in patients with Crohn’s ileitis, attempt to identify any associated risk factors, and determine whether it is justified to perform prophylactic cholecystectomy during ileocolic resection. METHODS: A total of 191 patients with Crohn’s ileitis who were treated medically or who had an ileocolic resection were retrospective reviewed. A questionnaire survey was performed. Telephone interviews were conducted for the nonrespondents. Further review of medical records was performed to determine the details of admissions for any gallstone disease and/or subsequent cholecystectomy. A control group matched for age and gender was obtained. RESULTS: A total of 191 questionnaires were mailed, and the overall response rate was 70.2 percent (134/191) after telephone interview follow-up. There were 2 of 45 medical and 18 of 89 surgical patients with symptomatic cholelithiasis, i.e., 14.9 percent (20/134) of respondents. As a result, 2 patients (1.5 percent) required endoscopic sphincterotomy, 17 patients (12.7 percent) needed cholecystectomy, and 1 patient (0.7 percent) did not have any intervention. Only five patients had a cholecystectomy after their ileal resections. In the control group of 150 patients, 15 patients (14 females; mean age, 51.9 years; range, 34–78 years) had previous cholecystectomy. There was no significant difference with prevalence of cholecystectomy in Crohn’s patients compared with controls (17/134 vs. 15/150; P = not significant). Furthermore, the number of ileal resections did not affect the cholecystectomy rate, but patients who had >30 cm of ileum resected were more likely to have cholecystectomy (P = 0.056). CONCLUSIONS: The prevalence of gallstone disease in Crohn’s ileitis requiring cholecystectomy is similar to that of the general population with a female predominance. In addition, the number of patients requiring cholecystectomy after ileal resection was low. Thus, synchronous prophylactic cholecystectomy during ileocolic resection for Crohn’s ileitis is not justified.

Randomized controlled trial of probiotics after colonoscopy.

Up to 20% of patients have ongoing abdominal symptoms at day 2 and beyond following colonoscopy. It was hypothesized that some of these symptoms are related to alterations in gut microbiota secondary to bowel preparation and would improve with probiotics compared with placebo.