Kheng-Hong Ng

Experience of 3711 stapled haemorrhoidectomy operations

Stapled haemorrhoidectomy has been routinely performed in the Department of Colorectal Surgery, Singapore General Hospital since 1999.

Cap Polyposis: Further Experience and Review

PURPOSE:Cap polyposis is characterized by the presence of inflammatory polyps with a “cap” of granulation tissue. It may represent one end of a spectrum of conditions caused by chronic straining. This experience represents the second largest reported series of cap polyposis.METHODS:The case notes of all patients with histologically proven cap polyposis were reviewed retrospectively and clinicopathologic features identified. A MEDLINE search was performed from 1985 to 2002 using cap polyps, polyposis, and inflammatory polyp as key words and further hand search was undertaken of key references.RESULTS:Eleven cases (9 males; median age, 20 (range, 15–54 years) of cap polyposis were diagnosed between 1993 and 2002. The commonest presenting symptoms were rectal bleeding (82 percent) and mucous diarrhea (46 percent). Chronic straining at stool and constipation were noted in seven of these patients (64 percent). Digital rectal examinations revealed polypoidal masses in the rectum in four patients (36 percent). All patients underwent colonoscopy. The commonest site of involvement was in the lower rectum (82 percent). One patient had polyps in the sigmoid colon and one patient in the transverse colon. Of 11 patients, 2 defaulted follow-up after colonoscopy. Three patients with solitary polyps had complete resolution of symptoms after polypectomy and remained symptom-free at three-month follow-up. The remaining six patients had persistent symptoms and required surgical intervention. Four underwent anterior resection and were all symptom-free at median of 48 (range, 18–72) months after surgery. One patient had transanal excision of rectal polyps and had recurrence at three months after surgery. This patient refused further treatment and remains symptomatic to date. One patient presented with recurrence of polyps at the coloanal anastomosis soon after a pull-through procedure. Total colectomy and ileal pouch-anal anastomosis was performed and the patient was free of symptoms at four months after surgery.CONCLUSIONS:Cap polyposis is eminently treatable with good long-term prognosis and function. Patients with solitary cap polyp respond well to endoscopic polypectomy. However, patients with multiple polyps and concurrent anorectal pathology require surgical resection.

Phenotypic characteristics of hereditary non-polyposis colorectal cancer by the Amsterdam criteria: an Asian perspective.

Background:  Hereditary non‐polyposis colorectal cancer (HNPCC) is an autosomal disease with a 68–82% lifetime risk of colorectal cancer (CRC). This study examined the phenotypic characteristics of CRC in Amsterdam criteria‐positive Asian patients from the Singapore Polyposis Registry.

Stapled hemorrhoidopexy for prolapsed piles performed with concurrent perianal conditions.

those who had lateral anal sphincterotomy undertaken concurrently. Of the 3 patients with fistula in ano, two had simple low anal fistulas that were laid open. SH was performed with the anastomosis proximal to the internal opening of the fistula. One of these patients had postoperative bleeding from the stapler line, which resolved with submucosae adrenaline injection. The other patient was readmitted 5 days after discharge from hospital for persistent perianal pain. This patient was treated symptomatically with simple oral analgesics and was discharged the following day. The third patient had an atypical horseshoe type of fistula in ano, with external openings at 3 and 9 o’clock positions and an internal opening at the 12 o’clock position. These tracts were laid open. However, the patient continued to have pain and fever postoperatively. This was attributed to a collection of pus at the base of the scrotum. Re-operation was done to drain the abscess. On the whole, 5 of 44 patients (11.3%) developed minor complications of bleeding, pain and localized abscess in the immediate postoperative period. None of these 44 patients developed major complications. The median pain score was 6 (range, 2–10) on the same day after operation, and 1 (range, 0–4) 2–4 weeks after surgery. All patients were fully continent and pain-free 8–12 weeks following surgery. The median overall satisfaction was 9 (range, 7–10). Pain scores and overall satisfaction for each of the concomitant conditions are shown in Table 1. There was an increase in the immediate postoperative pain when another procedure was undertaken to treat the concurrent perianal conditions. In view of this, surgeons must be prepared to counsel patients pre-operatively regarding the increase in pain after surgery. Our small study showed that SH can be performed in the presence of concurrent perianal conditions with minimal complications. However, the severity of postoperative pain C O R R E S P O N D E N C E

The fourth branch of the superior rectal artery and its significance in transanal haemorrhoidal dearterialisation.

IntroductionTransanal haemorrhoidal dearterialisation is a non-excisional surgical method for the treatment of haemorrhoidal disease. It uses a Doppler ultrasound probe to accurately identify the site to suture-ligate the piles, resulting in a decrease in the arterial inflow to the piles and their subsequent regression.MethodsA total of 140 consecutive patients who underwent transanal haemorrhoidal dearterialisation were studied. The number and locations of the haemorrhoidal arteries were documented. The presenting symptoms and their subsequent resolution were noted.ResultsThe median number of haemorrhoidal arteries ligated was four. Seventy-five patients (53.6%) had four haemorrhoidal arteries ligated. A total of 82 patients (58.6%) had a ‘fourth’ haemorrhoidal artery in the left anterior one o’clock position. Symptoms of bleeding, prolapse, pain and itching resolved in 92, 65, 68 and 60% of patients who presented with the respective symptoms preoperatively.ConclusionThere is a fourth haemorrhoidal artery consistently found in the left anterior one o’clock position. Adequate treatment of this artery minimises the recurrence of haemorrhoidal symptoms.

Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey

Background:  This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre.

Modified stapled haemorrhoidectomy: a suggested improved technique.

Background:  Longo’s technique of stapled haemorrhoidopexy has revolutionized management of symptomatic haemorrhoids. However, several problems have been identified in the original Longo’s technique. In particular, recurrence of haemorrhoidal tissue has been found to be significantly higher.

Laparoscopic resection for colorectal polyps: a single institution experience

Background:  Endoscopic polypectomy, although routinely used for the treatment of colorectal polyps, may be limited by polyp size, location and histology. Laparoscopic resection for malignant polyps and polyps not amenable to endoscopic removal has the advantage of adequate disease clearance as well as the short‐term benefits of laparoscopic surgery. This study evaluates the outcomes of such an approach.

Pneumoperitoneum resulting from pneumatosis cystoides intestinalis: a rare complication of massive colonic dilatation

A 69-year-old man presented with intestinal obstruction and peritonism. Chest and abdominal X-rays showed massive pneumoperitoneum with large bowel obstruction (Figs. 1, 2). Exploratory laparotomy revealed closed loop obstruction secondary to sigmoid volvulus with extensive pneumatosis cystoids intestinalis of non-dilated small bowel (Figs. 3, 4), without evidence of perforation. We postulate that rupture of a submucosal cyst in the small bowel resulted in pneumoperitoneum. Total colectomy was performed, with ileocecal anastomosis and defunctioning ileostomy. Histology confirmed pneumatosis cystoides intestinalis of small bowel without full-thickness perforation (Figs. 5, 6).

Salvaging a linear staple line defect in ultra-low anterior resection

The challenge of performing an ultra-low anterior resection has become technically possible with advances in surgical technique and equipment. The double stapled technique is frequently favored. Malfunction of equipment, however, can jeopardize an already difficult surgical procedure. Stapling across unhealthy tissue, such as irradiated rectal tissue, may also contribute. Two patients who underwent ultra-low anterior resections were noted to have a linear staple defect after linear stapling was performed. In these cases, an alternative to refashioning the anastomosis is to close the defect with handsewn sutures, incorporating the closed defect into the circular stapler. This was performed in both patients with good outcome. This technique can be used to salvage a defective staple line, as an alternative to refashioning the anastomosis.