Ian P. Bissett

ANASTOMOTIC LEAKAGE AFTER LOWER GASTROINTESTINAL ANASTOMOSIS: MEN ARE AT A HIGHER RISK

Background:  Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis.

RANDOMIZED CONTROLLED TRIAL OF GASTROGRAFIN IN ADHESIVE SMALL BOWEL OBSTRUCTION

Background:  Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non‐operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post‐administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non‐operative resolution of (ASBO).

Early ileostomy closure: is there a downside?

Background:  A loop ileostomy is a common adjunct to formation of a low colorectal anastomosis. However, it is not without significant physical and psychological morbidity, and financial cost. Feasibility of early closure during the index admission has previously been reported. This pilot study examines the safety of early closure compared with traditional timing.

Complex anal fistulas: plug or flap?

Background:  Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair.

Rectal perforation following transanal irrigation

A 57‐year‐old woman with a background of lifelong functional constipation and pelvic floor insufficiency was referred with obstructed defecation. Defecating proctogram showed high‐grade internal rectal intussusception which was treated with ventral mesh rectopexy. Post‐operatively, the patient complained of ongoing constipation, and 41 months following rectopexy, transanal irrigation with the Peristeen Anal Irrigation System (Peristeen Coloplast A/S, Humlebaek, Denmark) was trialled for symptom management. During the first attempt at irrigation, the patient noticed pelvic pain and developed a fever. A computerized tomogram identified a rectal perforation (Fig. 1) with retroperitoneal emphysema. Rigid sigmoidoscopy and laparotomy confirmed a posterior rectal perforation associated with extraperitoneal inflammation extending to the anterior mesorectum, which was initially drained by an incision in the mesorectal fascia just above the point of mesh fixation. An ultralow anterior resection, colon J‐pouch and loop ileostomy were performed and the Prolene mesh was excised with the specimen (Fig. 2). The patient made an uneventful recovery and had her ileostomy closed 2 months later, following which she described a deterioration of her continence. Histology confirmed a posterior rectal perforation with no underlying pathology. Transanal irrigation was first reported as an effective treatment for incontinence in children with spina bifida in 1987. Since then, it has been successfully applied as a treatment for selected patients with disordered defecation of neurogenic, functional or post‐surgical aetiology. The Peristeen irrigator allows daily evacuation of the left colon by tap water enema administered through a disposable rectal balloon catheter by the patient in the home environment. The most serious potential complication of this device is rectal perforation. The Peristeen irrigator has been commercially available for over 10 years and a recent long‐term (median 21 months) follow‐up study of 348 patients reported two bowel perforations in approximately 110 000 procedures (perforation risk 0.0002% per procedure). As each patient performs many irrigations, the per‐ patient risk is considerably higher (0.4% in the above series), although as perforation is most likely to occur in the first few months of use, the perforation rate is not directly cumulative. Rectal perforation following use of irrigation enemas is well documented. A literature review revealed one published case of rectal perforation related to Peristeen irrigation; however, an Internet search revealed 14 Device Adverse Event reports over a 16‐ month period documenting perforation requiring intervention, suggesting this complication may be more common. In many of the reports, reference is made to the instructions for use which state that ‘special caution must be shown if the patient has had underlying diseases or treatments leading to weakening of the bowel’ including ‘previous abdominal or anal surgery, cancer in the abdominal or pelvic region, or diverticular disease or obstruction’, including severe constipation. In one report, a history of surgery for rectal prolapse was noted. Others have listed a history of long‐term steroid medication use and radiotherapy to the pelvis as relative contraindications. As Peristeen irrigation is frequently used as a last option before colostomy in patients with functional bowel disorders, many patients will have had previous surgery or have coexisting diverticulosis as a manifestation of long‐standing dysfunction. In several of the adverse event reports, perforation occurred in the first few irrigation procedures, probably because of underlying bowel pathology. This has led to some advocating for a low threshold for flexible endoscopy before starting the treatment.

Self-adjusting your headlamp: a tip

The use of a headlamp by the operating surgeon to illuminate the operative field is common in colorectal practice. Adjustment of the non-sterile headlight to the right position can be difficult and time-consuming, as the task often falls to the lot of a hapless non-sterile assistant. We have developed the expediency of using the sterile plastic wrapper from opened surgical packs as a temporary ‘over-glove’ on the surgeon’s hand to personally adjust the headlight. At the commencement of the operation, the scrub nurse hands the surgeon the wrapper from a set of large (or medium) sterile packs (Fig. 1a). The surgeon places his glove inside the packaging and uses it to adjust the head lamp (Fig. 1b). Serendipitously the design of the wrapper has a flap, which is exploited by directing it towards the surgeon’s face and thereby preserving sterility during the adjustment maneuver. Once satisfied with the headlight’s position, the packaging can be shaken off the surgeon’s hand away from the sterile field and thereby safely discarded (Fig. 1c). This method is simple and we recommend its routine use. Tech Coloproctol (2006) 10:147 DOI 10.1007/s10151-006-0270-5

Postanal Pelvic Floor Repair

Postanal repair was developed by Sir Allan Parks in the 1970s [1] and popularised in the early 1980s for patients with neuromyopathic faecal incontinence. The original objective of this operation was to restore the anorectal angle, which was thought to be an important factor in continence. In 1975, Parks suggested the flap-valve theory that stressed the importance of the acute anorectal angle. According to this theory, a rise in intra-abdominal pressure caused the upper end of the anal canal to be occluded by anterior rectal mucosa, preventing rectal contents from entering the anal canal. Neuromyopathic faecal incontinence was associated with perineal descent and an obtuse anorectal angle, which rendered the flap-valve-like mechanism ineffective. Further investigations, however, failed to show changes of the anorectal angle, and currently, it is thought that an improvement of muscular contractility is responsible for any improvement in continence [2].

SE09 TRAINING OF FINAL YEAR MEDICAL STUDENTS IN PROCEDURAL SKILLS: IS IT WORTHWHILE?

Purpose  Doctors graduating from medical school are immediately faced with performing many clinical procedures. This study aimed to assess whether the introduction of a new procedural skills course for final year students increased their confidence in performing these skills at qualification.