Kong-Weng Eu

Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer

A defunctioning stoma is frequently created to minimize the impact of any subsequent anastomotic leak after a low rectal anastomosis. This review evaluates the need for routine stoma formation.

Perforation of the Gastrointestinal Tract Secondary to Ingestion of Foreign Bodies

Ingesting a foreign body (FB) is not an uncommon occurrence. Most pass through the gastrointestinal (GI) tract uneventfully, and perforation is rare. The aim of this study was to report our experience with ingested FB perforations of the GI tract treated surgically at our institution. A total of 62 consecutive patients who underwent surgery for an ingested FB perforation of the GI tract between 1990 and 2005 were retrospectively reviewed. Three patients with no definite FB demonstrated intraoperatively were included. The patients had a median age of 58 years, and 37 (60%) were male. Of the 59 FBs recovered, 55 (93%) were toothpicks and dietary FBs such as fish bones or bone fragments. A definitive preoperative history of FB ingestion was obtained for only two patients, and 36 of 52 patients (69%) wore dentures. Altogether, 18 (29%) perforations occurred in the anus or distal rectum, and 44 perforations were intraabdominal, with the most common abdominal site being the distal ileum (39%). Patients with FB perforations in the stomach, duodenum, and large intestine were significantly more likely to be afebrile (P = 0.043), to have chronic symptoms (> 3 days) (P < 0.001), to have a normal total white blood cell count (P < 0.001), and to be asymptomatic or present with an abdominal mass or abscess (P < 0.001) compared to those with FB perforations in the jejunum and ileum. Ingested FB perforation in the adult population is most commonly secondary to unconscious accidental ingestion and is frequently caused by dietary FBs especially fish bones. A preoperative history of FB ingestion is thus rarely obtained, although wearing dentures is a common risk factor. FB perforations of the stomach, duodenum, and large intestine tend to present with a longer, more innocuous clinical picture than perforations in the jejunum or ileum.

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.

Predictive Factors of Malignancy in Adults with Intussusception

Adult intussusception is an unusual entity, and its etiology differs from that in pediatric patients. The aim of this study was to evaluate our experience of 60 adult patients with intussusception and determine if there are any preoperative factors predictive of malignancy. The records of 60 adult patients (> 18 years of age) with a diagnosis of intussusception surgically treated at Singapore General Hospital and Changi General Hospital between 1990 and 2004 were retrospectively reviewed. The intussusceptions were classified as enteric or colonic. Preoperative predictive factors of malignancy were analyzed using univariate and multivariate analyses, and P < 0.05 was considered statistically significant. There were 60 patients with a median age of 57.5 years (range 21–85 years). Altogether, 34 (56.7%) patients were male, and there were 31 enteric and 29 colonic intussusceptions. A lead point was identified in 54 patients (90%). A total of 22 (36.7%) patients presented with intestinal obstruction, and the correct preoperative diagnosis of intussusception was made in 31 patients (51.7%). Computed tomography was the most useful diagnostic modality, correctly identifying an intussusception in 24 of 30 patients. A malignant pathology was present in 8 of 31 (26%) enteric versus 20 of 29 (69%) colonic intussusceptions. Age (P = 0.009), the presence of anemia (P < 0.001), and the site of the intussusception (P = 0.001) showed significant differences between the benign and malignant groups by univariate analyses. On multivariate analysis, intussusception in the colon (P = 0.004) and the presence of anemia (P = 0.001) were independent predictive factors of malignancy. Adult intussusception is most commonly secondary to a pathologic lead point. The site of intussusception in the colon and the presence of anemia are independent preoperative predictors of malignancy. All colonic intussusceptions should be resected en bloc without reduction, whereas a more selective approach can be applied for enteric intussusceptions.

Bioresorbable adhesion barrier facilitates early closure of the defunctioning ileostomy after rectal excision: a prospective, randomized trial.

INTRODUCTION A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis from an anastomotic dehiscence after a coloanal or low colorectal anastomosis. Such a stoma is usually closed after 6 to 12 weeks when the intestinal edema is reduced and the peristomal adhesions are less dense. This period is three to four times longer than necessary for assurance of anastomotic healing, which is usually achieved by the second week after surgery. With the use of a bioresorbable membrane to minimize the formation of peristomal adhesions, earlier closure is hypothetically possible at three weeks. METHODS Patients undergoing creation of a defunctioning ileostomy were randomized in Phase I either to have an adhesion barrier membrane wrapped around the limbs of the ileostomy, with closure at three weeks, or to the control group, with no barrier membrane and closure after more than six weeks. In the subsequent Phase II, the efficacy of the barrier membrane was compared in a similar manner with a control group at ileostomy reversal after three weeks. Peristomal adhesions at the time of stomal mobilization were scored in a blinded manner. RESULTS In Phase I, no statistically significant differences were noted in the mean adhesion scores between the two groups (7.42 vs. 7.28). However, in Phase II, when peristomal adhesions at closure were compared at three weeks for both groups, with and without adhesion barrier placement, there was a significant reduction in the overall mean adhesion scores (5.81 vs. 7.82, respectively). The number of patients with dense adhesions was also reduced in the adhesion barrier group. There was no significant difference in the time taken and the difficulty encountered during ileostomy closure in the two groups. A tendency to easier closure, as evidenced by a lower incidence of perioperative complications, was noted in the adhesion barrier group. CONCLUSION An adhesion barrier membrane placed around the limbs of a defunctioning loop ileostomy reduces peristomal adhesion and facilitates early closure at three weeks with minimal complications.

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.

Mortality, morbidity and functional outcome after total or subtotal abdominal colectomy in the Asian population.

Objective:  This study reviews the functional outcome and satisfaction of patients after subtotal or total colectomy (STTC).

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.