Per-Olof Nyström

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation

An international working party was convened in Rome, Italy on 16–17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so‐called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

Safety of the temporary loop ileostomy

Objective To evaluate the complications of the temporary loop ileostomy.

Thiopurine therapy is associated with postoperative intra-abdominal septic complications in abdominal surgery for Crohn's disease.

PURPOSE: Thiopurines are important as maintenance therapy in Crohn’s disease, but there have been concerns whether thiopurines increase the risk for anastomotic complications. The present study was performed to assess whether thiopurines alone, or together with other possible risk factors, are associated with postoperative intra-abdominal septic complications after abdominal surgery for Crohn’s disease. METHODS: Prospectively registered data regarding perioperative factors were collected at a single tertiary referral center from 1989 to 2002. Data from 343 consecutive abdominal operations on patients with Crohn’s disease were entered into a multivariate analysis to evaluate risk factors for intra-abdominal septic complications. All operations involved either anastomoses, strictureplasties, or both; no operations, however, involved proximal diversion. RESULTS: Intra-abdominal septic complications occurred in 26 of 343 operations (8%). Thiopurine therapy was associated with an increased risk of intra-abdominal septic complications (16% with therapy; 6% without therapy; P = 0.044). Together with established risk factors such as preoperative intra-abdominal sepsis (18% with sepsis; 6% without sepsis; P = 0.024) and colo-colonic anastomosis (16% with such anastomosis; 6% with other types of anastomosis; P = 0.031), thiopurine therapy was associated with intra-abdominal septic complications in 24% if any 2 or all 3 risk factors were present compared with 13% if any 1 factor was present, and only 4% in patients if none of these factors were present (P < 0.0001). CONCLUSIONS: Thiopurine therapy is associated with postoperative intra-abdominal septic complications. The risk for intra-abdominal septic complications was related to the number of identified risk factors. This increased risk should be taken into consideration when planning surgery for Crohn’s disease.

Defunctioning stoma in low anterior resection with colonic pouch for rectal cancer: a comparison between two hospitals with a different policy.

AbstractPURPOSE: The aim of this study was to compare surgical outcome, after low anterior resection for rectal cancer with colonic J-pouch, at two departments with a different policy regarding the use of a routine diverting stoma. METHODS: A total of 161 consecutive patients with invasive rectal carcinomas operated on between 1990 and 1997 with a total mesorectal excision and a colonic J-pouch were included in the study. Eighty patients were operated on in a surgical unit using routine defunctioning stomas (96 percent), whereas 81 were operated on in a department in which diversion was rarely used (5 percent). Recorded data with respect to surgical outcome were analyzed and compared. RESULTS: There was no difference between the two centers in postoperative mortality in connection with the primary resection and subsequent stoma reversal (3.7 vs. 3.8 percent). No significant difference could be found in the number of patients with pelvic sepsis (anastomotic leaks; 9 vs.12 percent). Surgical outcome in patients with pelvic sepsis was also similar. The frequency of reoperations associated with the anterior resection and subsequent stoma reversal was identical (14 percent). The total hospital stay (primary operation and stoma reversal) was significantly longer with than without a routine stoma (17 (range, 2–59) vs. 12 (range, 5–55) days, respectively; P < 0.001). CONCLUSION: This study suggests that the routine use of diversion does not protect the patient from anastomotic complications or pelvic sepsis and its use requires a second admission for closure.

Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years

BackgroundThe aim of our study was to assess our early and long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids.MethodsOur study covers the time period from 1998 to 2002 and consists of 56 consecutive patients (33 men) with fourthdegree haemorrhoids who underwent stapled haemorrhoidopexy.ResultsDuring the postoperative period, 6 patients (10.7%) experienced pain for 7–14 days, which was treated with oral analgesia. Ten patients (17.8%) experienced gas incontinence and two of them also reported soiling. The incontinence subsided within 3–4 weeks. Median follow-up was 72.1 months (range, 55–56 months). Recurrence of the haemorrhoidal disease occurred in 33 patients (58.9%). The overall reintervention rate was 42.8%, as 24 patients required excisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage.ConclusionsStapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of fourth-degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term.

Audit of anal‐sphincter repair

Structural damage of the anterior part of the anal sphincter is a major cause of faecal incontinence. Sphincter repair is the standard surgical treatment. This study was designed to analyse the results of anal sphincter repair, to identify possible predictors of outcome and to investigate the presence of bowel symptoms other than leakage at follow up.

An evidence-based treatment algorithm for anal fissure

AbstractGuidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings.

A controlled trial of a plastic wound ring drape to prevent contamination and infection in colorectal surgery

A controlled, randomized study of the efficacy of a plastic wound ring drape (Opdrape, Triplus) to prevent contamination and infection in elective colorectal operations is reported. Seventy patients were operated upon with the wound ring drape and 70 patients without. All patients received preoperative systemic antibiotic prophylaxis. Abdominal wound infection was observed in seven of 70 (10 per cent) patients with the wound ring drape and six of 70 (9 per cent) without (N.S.). An operative swab for bacteriologic evaluation was obtained from 85 per cent of the wounds. There was no evidence that the drape protected the wound from contamination with intestinal bacterial flora. It was concluded that the wound ring drape prevents neither contamination nor infection.

Surgery for Crohn Colitis Over a Twenty-Eight-Year Period: Fewer Stomas and the Replacement of Total Colectomy by Segmental Resection

Background: This study describes how surgery for Crohn colitis developed between 1970 and 1997, towards the end of which period limited resection and medical maintenance treatment was introduced. Methods: A cohort of 211 patients with Crohn colitis (115 population-based), of which 84 had a primary colonic resection (42 population-based), was investigated regarding indication for surgery, the time from diagnosis to operation, type of primary colonic resection, risk for permanent stoma and medication over four 7-year periods. Results: Comparison of the periods 1970-90 and 1991-97 revealed that active disease as an indication for surgery decreased from 64% to 25% ( P < 0.01) while stricture as an indication increased from 9% to 50% ( P < 0.001). Median time from diagnosis to operation increased from 3.5 to 11.5 years ( P < 0.01). Proctocolectomy or colectomy fell from 68.8% to 10% of the primary resections, whereas segmental resection increased from 31.2% to 90%. At the end of the first 7-year period, 26% had medical maintenance treatment, steroids or azathioprine taken by 7%. Corresponding figures for the last period were 70% and 49%. Patients diagnosed during the last two time-periods had less risk for surgery ( P = 0.017), permanent stoma ( P < 0.01) and total colectomy ( P < 0.01). Findings were similar in the population-based cohort. Conclusions: Current management of Crohn colitis implies a longer period between diagnosis and surgery, a reduced risk for surgery and permanent stoma, and the replacement of total colectomy by segmental resection.

Local perianal block for anal surgery

Abstract.Background:We refined a technique for local block of all terminal nerve branches to the anus.Methods:A total of 30 consecutive patients with proctological disorders consented to ambulatory (n=29) or hospitalised (n=1) operation with local perianal block for skin tags, Milligan- Morgan haemorrhoidectomy, stapled haemorrhoidopexy or anocutaneous fistulae. Patients were operated prone. A total of 40 ml of a 4.75 mg/ml solution of ropivacaine (Narop; Astra, Sweden) was injected in 8 directions (5 ml each) into the ischiorectal fat immediately peripheral to the external sphincter as anaesthetic columns reaching from the skin to the levator. This injection scheme targets the terminal nerve branches of the anus rather than blocking the trunk of major nerves. The relaxation of a pain-free anus was obtained in 2–3 minutes with exposure similar to a general anaesthetic. Postoperative pain was evaluated on a 0 to 10 visual analogue scale (VAS).Results:Patients were pain-free at discharge. However, mean postoperative VAS score at 24 hours was 3.2 following Milligan-Morgan haemorrhoidectomy, 4.8 following stapled haemorrhoidopexy and skin tags or polyps excision, and 2.7 after fistula lay-open. At telephone follow-up 1–2 weeks later, the patients were satisfied with the method of anaesthesia and would willingly accept it for any further anal surgery.Conclusions:The perianal block is easy to apply and effective as sole method of anaesthesia for proctological operations.