Kok-Sun Ho

Experience of 3711 stapled haemorrhoidectomy operations

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

Prospective randomized trial comparing stapled hemorrhoidopexy versus closed Ferguson hemorrhoidectomy

AbstractBackgroundFerguson hemorrhoidectomy is believed to result in less postoperative pain because of a closed wound. Stapled hemorrhoidopexy, without a perianal wound, should thus have lesser pain. We conducted a prospective randomized trial to compare stapled hemorrhoidopexy (SH) with Ferguson hemorrhoidectomy (FH).MethodsFifty patients with third-degree or early fourthdegree hemorrhoids who required surgery were recruited. Patients were prospectively randomized to receive either FH or SH. Data collected include operative time, hospital stay, fecal incontinence and pain scores, morbidity and complications.ResultsSH patients had less pain in the early postoperative period. There were no significant differences in hospital stay or major complications. One patient after SH required emergency reintervention for thrombosed hemorrhoids distal to the staple line. FH patients had more minor problems of bleeding, wound discharge and pruritus. Fecal incontinence was similar in the 2 groups but two of the three patients with daily incontinence to gas after SH claimed that their lifestyle was affected.ConclusionsSH is safe to perform and results in less postoperative pain as well as less minor morbidity. Early reintervention and incontinence to gas compromising lifestyle occurred only after SH.

Genome‐wide scan identifies a copy number variable region at 3q26 that regulates PPM1L in APC mutation‐negative familial colorectal cancer patients

Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited form of colorectal cancer (CRC) caused by mutation in the adenomatous polyposis coli (APC) gene. However, APC mutations are not detected in 10–50% of FAP patients. We searched for a new cancer gene by performing genome‐wide genotyping on members of an APC mutation‐negative FAP variant family and ethnicity‐matched healthy controls. No common copy number change was found in all affected members using the unaffected members and healthy controls as baseline. A 111 kb copy number variable (CNV) region at 3q26.1 was shown to have copy number loss in all eight polyps compared to matched lymphocytes of two affected members. A common region of loss in all polyps, which are precursors to CRC, is likely to harbor disease‐causing gene in accordance to Knudsens “two‐hit” hypothesis. There is, however, no gene within the deleted region. A 2‐Mb scan of the genomic region encompassing the deleted region identified PPM1L, coding for a novel serine‐threonine phosphatase in the TGF‐β and BMP signaling pathways. Real‐time PCR analyses indicate that the 3′UTR of PPM1L transcript was down‐regulated more than two‐folds in all six polyps and tumors compared to matched mucosa of the affected member. This down‐regulation was not observed in APC mutation‐positive FAP patients. Our results suggest that the CNV region at 3q26 harbors an element that regulates the expression of an upstream candidate tumor suppressor, PPM1L, thus providing a novel mechanism for colorectal tumorigenesis in APC mutation‐negative familial CRC patients.

PPH03 stapled hemorrhoidopexy: our experience

BackgroundStapled hemorrhoidopexy is an established treatment for hemorrhoidal disease. We evaluated our experience with stapled hemorrhoidopexy using the new Procedure for Prolapse and Hemorrhoids (PPH03) Proximate HCS hemorrhoidal circular stapler (Ethicon Endo–Surgery).MethodsWe retrospectively reviewed clinical data for 238 patients who had undergone stapled hemorrhoidopexy in our department over a 2–month period. Patients were followed–up for a median of 3.5 weeks (range, 1–11 weeks) and were analyzed for complications and resolution of symptoms.ResultsThe hemorrhoids treated were third– and fourth–degree, as well as second degree (after failure of other therapies). Mean duration of surgery was 12.7 minutes (range, 5–20 minutes) and the majority of patients was treated with an ambulatory procedure. Most patients were discharged within 6 hours after surgery. On follow–up, 3.7% of patiets had minor complaints after surgery. Technically, the new PPH03 stapler device has a quickclose knob, which allows rapid opening and closing. The closed staple height of 0.75 mm increases staple line compression on tissue and key blood vessels, hence minimizing bleeding. Prior to this, stapled hemorrhoidopexy was done using the PPH01 device.ConclusionsStapled hemorrhoidopexy using the new PPH03 stapler is a safe, short and effective procedure in the management of hemorrhoids. It can be done in the ambulatory setting and patients have few postoperative complications.

Dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection for rectal tumour

AimTo review the results of dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection (APR) for rectal cancer.Patients and methodsChart reviews were done on 17 patients who had dynamic graciloplasty following abdominoperineal resection and details of post-operative complications, bowel functions and recurrences were obtained.ResultsSeventeen patients (12 males) had dynamic graciloplasty after APR for low rectal tumours. The median age was 58.5 years (range 33–78). Three patients from overseas were lost to follow-up, and three still have not had the defunctioning stoma closed. Only 11 patients were available for evaluation of function. The median time from graciloplasty to continence to solids and liquids is 15.7 months (range 0.4–21.9 months). Six patients had defecatory problems, requiring daily irrigation to evacuate. Nine patients were continent without need for gracilis stimulation. Only two patients needed gracilis stimulation to maintain continence. Fifty percent of rectal carcinoma patients had developed a recurrence.ConclusionDynamic graciloplasty had a high morbidity and did not always bring about normal defecatory function. Gracilis stimulation was not needed to achieve continence in all cases. Conversely, dynamic graciloplasty may lead to defecatory difficulties in a large number of patients. Graciloplasty should only be considered three years after the initial APR to avoid performing the procedure in a patient who may develop recurrence as well as to select patients who are psychologically prepared for the surgery and its complications.

Adenocarcinoma of the anal transitional zone after double stapled ileal pouch‐anal anastomosis for ulcerative colitis

The development of adenocarcinoma in the anal transitional zone, after restorative proctocolectomy for ulcerative colitis, is rare. We report the first Asian and sixth known case. A 41‐year‐old Indian lady had a long standing history of ulcerative colitis. Restorative proctocolectomy and stapled ileal pouch‐anal anastomosis without mucosectomy was performed. She remained asymptomatic until 3 years later when she complained of discomfort on defecation. A poorly differentiated adenocarcinoma in the anal transition zone was diagnosed and she subsequently underwent an abdomino‐perineal resection. The previously reported cases in the literature are reviewed. We also discuss the suggested surveillance for high‐risk patients who have undergone an ileal‐anal pouch anastomosis.

Prospective randomized crossover trial comparing fibre with lactulose in the treatment of idiopathic chronic constipation

AbstractBackgroundFibre is often recommended as the first-choice treatment but its effects can be uneven. The aim of the study was to compare the clinical efficacy and tolerability of fibre versus lactulose in outpatients with chronic constipation.MethodsIn a prospective randomized crossover trial, patients were randomized to receive fibre or lactulose for four weeks. Between treatments, patients had at least one week free of laxatives.Results50 patients, of median age 50 years (range, 18–85) were recruited and 39 patients completed the trial. Compared to fibre, lactulose resulted in significantly higher mean bowel frequency (7.3, 95% CI 5.7 to 8.9 vs. 5.5, 95% CI 4.4 to 6.5; p=0.001) and stool consistency score (3.4, 95% CI 3.1 to 3.7 vs. 2.9, 95% CI 2.5 to 3.3; p=0.018). Scores for ease of evacuation were similar. The frequencies of adverse effects were not significantly different, but greater in the lactulose group. Mean patients’ recorded improvement score was significantly higher after taking lactulose than fibre (6.2, 95% CI 5.5 to 7.0 vs. 4.8, 95% CI 4.0 to 5.9; p=0.017). Of the 39 patients who completed the trial, 24 (61.5%) preferred lactulose and 14 (35.9%) preferred fibre.Conclusions Lactulose had better efficacy than fibre for chronic constipation in ambulant patients, although both treatments were equally well tolerated in terms of adverse effects.

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.

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.

A prospective study assessing anal plug for containment of faecal soilage and incontinence

Objective  Faecal incontinence is a common and embarrassing problem for many individuals. Some patients remained symptomatic despite the availability of different treatments. There is a limited range of commercially available products designed to cope with faecal incontinence. The anal plug has been developed to contain the loss of stool. This study aimed to evaluate the use of anal plug in Asian patients with intractable faecal soilage and incontinence judged by clinical and functional outcomes.