Richard J. Guy

Physiologic responses to primary blast.

BACKGROUND Primary blast injuries are produced by the blast shock wave. The critical determinant of survival is pulmonary injury, but acute cardiorespiratory responses to blast exposure are not well understood. The aim of this study was to investigate these changes. METHODS Twenty anesthetized rats were exposed to moderate blast overpressure, 10 animals receiving thoracic and 10 receiving abdominal exposure. Another 9 animals acted as controls. Respiration, heart rate, and blood pressure were recorded continuously before, during, and for 6 hours after blast exposure. RESULTS All animals exposed to thoracic blast demonstrated apnea, bradycardia, and hypotension after blast exposure, followed by a return to preblast values. No significant cardiovascular or respiratory changes were seen in animals in the other groups. CONCLUSION Moderate thoracic blast injury produces a reflex triad of apnea, bradycardia, and hypotension that is not present after abdominal blast. These observations may have important implications for the immediate management of patients with blast injuries.

Influence of risk factors on the safety of ileocolic anastomosis in Crohn's disease surgery.

BACKGROUND: Ileocecal resection is the most commonly performed operation in patients with Crohn’s disease. Anastomotic-associated complications, with their associated morbidity, are the most feared risks of surgery. OBJECTIVE: This study aimed to assess the influence of a variety of putative risk factors in a homogenous group of patients undergoing first or subsequent surgery for Crohn’s disease to quantify the cumulative risk for anastomotic-associated complications. DESIGN AND PATIENTS: All patients undergoing ileocecal or ileocolic resections for Crohn’s disease from 2000 to 2010 were studied with the use of a prospective database. Demographics, operative details, possible risk factors, and anastomotic-associated complications were recorded. Patients having strictureplasties, multiple resections, or subtotal colonic resections were excluded from analysis. Statistical analysis was by univariate analysis (Mann-Whitney U test) and binary logistic regression. OUTCOMES: An anastomotic-associated complication was defined as a proven anastomotic leak, postoperative fistulation, or intra-abdominal abscess formation. RESULTS: Two hundred seven patients (109 female) with a median age of 35 years (range, 13-75 years) were identified. One hundred seventy-three underwent primary anastomosis, 94 as an emergency procedure. Fifty-three had laparoscopic (5 converted) procedures. Nineteen of 173 anastomotic complication events (11%) were recorded. Steroid usage (OR 2.67, 95% CI 1.0-7.2) and the presence of preoperative abscess formation (OR 3.4, 95% CI 1.2-9.8) were identified as independent predictors of anastomotic-associated complications. In the absence of both steroids and intra-abdominal abscess, the risk of anastomotic complications was 6%, which increased to 14% if either risk factor was present. When both risk factors were present, complication rates reached 40%. CONCLUSION: Steroid usage and preoperative abscess were associated with higher rates of anastomotic complications following ileocolic resection for Cohn’s disease. When both risk factors are present, it is best to avoid primary anastomosis.

A two centre experience of transanal total mesorectal excision.

Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two‐centre experience of this technique, focusing on the short‐term and oncological outcome.

Transanal rectal resection: an initial experience of 20 cases.

Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique.

Endoscopically assisted extralevator abdominoperineal excision

Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position.

What To Do With Lateral Nodal Disease in Low Locally Advanced Rectal Cancer? A Call for Further Reflection and Research

BACKGROUND: There remains a lack of international consensus on the appropriate management of lateral nodal disease. Although the East manages this more aggressively with lateral lymph node dissections, the West aims to eradicate small-volume disease with neoadjuvant chemoradiotherapy and lateral nodal disease is not considered for routine surgical treatment. However, recent studies have shown that, despite neoadjuvant treatment, a significant number of patients with lateral nodal disease develop local recurrence in the lateral compartment after total mesorectal excision. OBJECTIVE: The aim of this study is to assess the role of the pretreatment features of lateral nodes on MRI in regard to local recurrence. DESIGN: All patients operated on for low locally advanced rectal cancer over a 5-year period were evaluated retrospectively. SETTINGS: This study was conducted at a single expert center. PATIENTS: The MRIs of a total of 313 patients were reviewed, and only those with rectal cancers up to 8 cm from the anorectal junction, measured on MRI, were selected. This left 185 patients; of these, 58 patients had clinical T1 or T2 tumors as assessed on MRI, identifying 127 patients who had cT3/T4 tumors that were included in this study. MAIN OUTCOME MEASURES: The primary outcomes measured were lateral local recurrence and multivariate analyses. RESULTS: The lateral local recurrence rate was significantly higher (33.3% 4-year rate) in patients with nodes larger than 10 mm than in patients with smaller nodes (10.1%, p = 0.03), despite patients being irradiated in the lateral compartment. LIMITATIONS: Because this is a relatively uncommon disease, patient numbers are low, and a multicenter study is needed to further address lateral nodal disease in low rectal cancer. CONCLUSIONS: Chemoradiotherapy with total mesorectal excision might not be sufficient in a selected group of patients. Further research is needed about which pretreatment features of the lateral nodes predict local recurrence and what is needed to prevent these from developing. See Video Abstract at http://links.lww.com/DCR/A338.

Management of Tumors of the Ischiorectal Fossa: The Role of Percutaneous Biopsy.

BACKGROUND: Noninflammatory masses in the ischiorectal fossa are rare. OBJECTIVE: This study aimed to review our experience with ischiorectal fossa tumors and to address the question of whether percutaneous biopsy should be undertaken. DESIGN: This is a retrospective study. SETTINGS: This study was conducted at a tertiary institution. PATIENTS: From April 2007 to November 2014, all consecutive ischiorectal fossa masses treated in a referral center were retrospectively reviewed. They were all presented and discussed in a multidisciplinary team meeting. Magnetic resonance imaging was performed in all the patients. Inflammatory pathologies, such as abscess, were excluded from the analysis. INTERVENTIONS: Percutaneous biopsy and surgical excision of ischiorectal fossa tumors were reviewed. MAIN OUTCOME MEASURES: Perioperative, pathological, and oncological outcomes were measured. RESULTS: Eleven patients were identified (8 female; median age, 50 years; range, 25–90). Percutaneous biopsy was undertaken in 8 patients. All biopsies were diagnostic and altered preoperative management in 3 cases (aggressive angiomyxoma (n = 2), desmoid fibromatosis (n = 1)). Overall final diagnosis was benign in 3 patients, locally aggressive neoplasm in 3, and malignant in 5 cases (leiomyosarcomas (n = 2), liposarcomas (n = 2), and angiomyosarcoma (n = 1)). Surgical approaches were perineal in 8 patients, abdominoperineal in 1 patient, and totally abdominal in 1 patient. One patient (age 90 years) was managed nonsurgically. After resection, 2 positive margins were observed (R1 rate, 20%). After a mean follow-up of 24.3 months, 3 patients have experienced local recurrence, which required further surgery in 2 cases. LIMITATIONS: This study is limited by the small number of patients. CONCLUSIONS: Noninflammatory masses in the ischiorectal fossa are rare, but they are commonly malignant and should be imaged by MRI. Unless the radiological appearances are diagnostic, percutaneous biopsy is recommended and alters management in about one-third of cases.

Transanal total mesorectal excision with a side-to-end stapled anastomosis - a video vignette.

Dear Editor, Low mesorectal dissection can be difficult and we find it helps to do some of the lowermost part of the total mesorectal excision dissection from below using a transanal approach. This also needs some modification of the typical mechanical stapling method in order to allow the standard circular stapling devices to be used. The transanal approach allows for double pursestring stapling and avoids the cumbersome, technically challenging cross-stapling of the distal rectum. The main difficulty with the double purse-string technique is the short length of the centre rod of the standard circular stapler devices. This makes it difficult to secure the distal purse-string onto the centre rod in preparation for the anastomosis. The 33 mm Covidien EEA Hemorrhoid and Prolapse Stapler gun (AutoSuture; Covidien, Dublin, Ireland) has an extended reach (13.5 cm) of the centre rod which allows for sufficient access to secure the purse-string onto the spindle/rod. While this stapler has proved to be safe for low colorectal joints after the transanal approach, we feel that the amount of tissue incorporated into the stapler is excessive. In particular we worry about incorporating sphincter fibres for truly low stapled anastomoses. We have therefore modified our technique in an effort to use the standard 28/29 mm or 31 mm circular staplers by using a standard redivac drain (10 F) as an extension of the centre rod. Here, in this video vignette, we detail the use of our technique for a side-to-end double purse-string stapled low anastomosis.

Impact of the consideration of serrated polyps to the interval of colonoscopic surveillance in the NHS Bowel Cancer Screening Programme

Most international post polypectomy surveillance guidelines do not recommend surveillance for serrated polyps. In the present study the additional impact of serrated polyps on surveillance intervals from international adenoma surveillance guidelines was investigated.

Persistent colitis after emergency laparoscopic subtotal colectomy for ulcerative colitis: a cautionary note.

Dear Sir, The place of colectomy with ileostomy formation for acute severe colitis that does not respond to medical therapy is well established [1,2]. For decades surgeons have debated the optimal management of the retained rectal stump. Traditional options after open colectomy included leaving an open mucous fistula, a long rectosigmoid remnant closed subcutaneously [3], closure at the sacral promontory or closure at the level of pelvic floor. Although there are no comparative trials there is some evidence that closure at the level of the pelvic floor is associated with a high risk of pelvic sepsis [4]. Laparoscopic subtotal colectomy (STC) is associated with reduced morbidity and shorter recovery and may facilitate future reconstruction [5–7]. Most surgeons divide the rectosigmoid junction around the level of the sacral promontory using an endoscopic stapler device. A rectal catheter is generally recommended to reduce the risk of dehiscence of the rectal stump suture line. In rare cases of extremely severe inflammation, where stapled closure is not secure, an open mucous fistula is recommended. We recently encountered two cases of persisting proctocolitis following laparoscopic colectomy, which we believe were related to an excessively long rectosigmoid stump. Two young men (27 and 31 years old) both underwent laparoscopic STC in other institutions for medically refractory acute severe colitis. Following surgery both presented with severe rectal bleeding with mucus, which did not respond to topical steroids or mesalazine. Both required renewed treatment with high-dose oral steroids. One patient required a six-unit blood transfusion over a 5 weeks. In both cases, flexible sigmoidoscopy showed a rectosigmoid stump of 35 and 45 cm. Surgery was undertaken and in both cases a long loop of distal sigmoid colon was found. The colon was resected to the level of the promontory. Restorative proctectomy with pouch reconstruction was not considered at that stage owing to the high dose of oral steroids and the low serum albumin. Postoperatively, steroids were gradually withdrawn in both patients and one has subsequently undergone a proctectomy with ileoanal pouch reconstruction. The other patient is well, on no medication and is planning for pouch reconstruction next year. To the best of our knowledge, a long rectal stump causing persistence of symptoms related to severe ulcerative colitis after STC has not previously been reported. This emphasizes the need at the time of emergency colectomy to divide the bowel close to the rectosigmoid junction rather than mid-sigmoid in patients with severe inflammation of the sigmoid. It is acknowledged that assessing the level of division may be difficult laparoscopically in the presence of a severely inflamed colon, but stretching the rectal stump to the level of the sacral promontory used as a landmark may help to determine the best point of transection. On the other hand it is important to appreciate that too short a rectal stump may not be ideal since it will be impossible to exteriorize the distal bowel in the event of dehiscence of the rectal stump and it may be more difficult to identify the rectum when performing a proctectomy during subsequent surgery. While it is difficult to draw definite conclusions from only two cases, the decision regarding the point of division of the rectal stump, either long to create a mucous fistula or short to be at the level of the sacral promontory, should be taken at the beginning of the operation. If a mucous fistula is not an option, leaving a long rectal stump is not indicated since it may cause persisting severe rectal bleeding and discharge of mucus.