Ridzuan Farouk

Sustained internal sphincter hypertonia in patients with chronic anal fissure

PURPOSE: This study was designed to determine whether functional variations of internal sphincter activity occur in order to differentiate between patients with anal fissures from those with hemorrhoids. METHODS: Thirty patients with chronic anal fissure (median age, 28 years; 12 females), 22 patients with hemorrhoids (median age, 37 years; 7 females), and 33 control volunteers (median age, 48.5 years; 21 females) underwent ambulatory anal sphincter fine-needle electromyography and anorectal manometry. RESULTS: The median internal sphincter electromyography frequency was similar: fissure group, 0.49 Hz; hemorrhoid group, 0.46 Hz (P>0.05), and control group, 0.44 Hz (P>0.05). Median anal resting pressures were similar in the fissure group (132 cm. H2O) and the hemorrhoids group (116 cm of H2O) (P>0.05), but significantly greater than those in the control group (94 cm. H2O) (P<0.05). The median number of transient relaxations of the internal anal sphincter with an associated rise in rectal pressure and fall in anal pressure was 1 (range, 0–4) per hour in the fissure group, 6 (range, 4–7) per hour in the hemorrhoid group, and 4 (range, 3–6) per hour in the control group. Six patients with fissures were reassessed following lateral internal sphincterotomy. Median anal pressure was 102 cm of H2O (P>0.1vs.controls) and the number of internal sphincter relaxations increased to 4 per hour (P<0.01vs.preoperative number). CONCLUSIONS: Internal anal sphincter relaxation occurs on fewer occasions in patients with chronic anal fissures that have failed to heal in comparison to patients with hemorrhoids and normal controls. This evidence further supports the hypothesis that internal sphincter hypertonia may be relevant to the pathogenesis of this disorder.

Sacral Nerve Stimulation Can Be Successful in Patients With Ultrasound Evidence of External Anal Sphincter Disruption

PURPOSEThis study was designed to determine whether patients with fecal incontinence and endoanal ultrasound evidence of anal sphincter disruption may be successfully treated by sacral nerve stimulation.METHODSFive consecutive females with incontinence to solids and endoanal ultrasound evidence of anal sphincter disruption were treated by a two-week trial of sacral nerve stimulation. If successful, patients then proceeded to permanent sacral nerve stimulation implantation.RESULTSFive patients, aged 34 to 56 years, were treated by temporary sacral nerve stimulation. Four had symptoms starting after childbirth. Two had previously had an anterior sphincter repair. After a two-week trial, three females reported full continence and an improvement in all aspects of their Rockwood fecal incontinence quality of life scores. These three females underwent permanent sacral nerve stimulation implantation. The remaining two patients reported no improvement and underwent dynamic graciloplasty or end colostomy respectively.CONCLUSIONSSacral nerve stimulation may successfully restore bowel continence in some patients with endoanal ultrasound evidence of a defect in their external anal sphincter.

The incidence and causes of permanent stoma after anterior resection

Aims Defunctioning stomas are used following anterior resection to guard against the serious consequences of anastomotic leak such as pelvic sepsis and generalized peritonitis. This study aims to determine what proportion of patients undergoing anterior resection have a defunctioning stoma, how many of these patients do not have their stoma closed, and the reasons for this.

A Comparison of POSSUM, P-POSSUM and Colorectal POSSUM for the Prediction of Postoperative Mortality in Patients Undergoing Colorectal Resection

PurposePOSSUM (Physiologic and Operative Severity Score for enUmeration of Morbidity & Mortality) and P-POSSUM have been validated as scoring tools for the prediction of postoperative complications in general surgical patients. More recently a colorectal-specific POSSUM has been developed for mortality prediction. This study was designed to evaluate and compare the accuracy for mortality prediction of POSSUM, P-POSSUM, and colorectal POSSUM after major and complex major colorectal procedures.MethodsThe relationship between the observed and expected morbidity and mortality was examined in 347 consecutive patients (321 elective, 26 urgent) undergoing a major or complex major colorectal resection using POSSUM, P-POSSUM, and Colorectal POSSUM. The accuracy of using these scoring tools to predict mortality was assessed using Receiver Operator Characteristic curve analysis.ResultsA total of 347 consecutive patients (median age, 69 (range, 34–92) years) were assessed. Seventy-one patients (20.5 percent) suffered a postoperative complication and 15 patients (4.3 percent) died. The observed: expected POSSUM ratio for morbidity was 0.71 and mortality 0.68. The area under curve from Receiver Operator Characteristic curve analysis for POSSUM was 0.752. The observed:expected mortality ratio for P-POSSUM was 0.71, and the area under curve from Receiver Operator Characteristic curve analysis was 0.749. The observed:expected mortality ratio for colorectal POSSUM was 0.75, and the area under the curve from Receiver Operator Characteristic curve analysis was 0.781.ConclusionsColorectal POSSUM provides comparable prediction of mortality risk after colorectal resection compared with POSSUM and P-POSSUM.

Doppler-Guided Hemorrhoid Artery Ligation Reduces the Need for Conventional Hemorrhoid Surgery in Patients who Fail Rubber Band Ligation Treatment

PURPOSE: This study was designed to assess whether Doppler-guided hemorrhoid artery ligation can prevent patients from needing conventional surgery when rubber band ligation of their hemorrhoids has failed to achieve symptomatic relief. METHODS: All patients who underwent treatment for hemorrhoids in two hospitals between September 2004 and June 2007 are reported. RESULTS: A total of 203 patients (121 women; mean age, 44 (range, 17-84) years) were treated by rubber band ligation for two (181 patients) or three hemorrhoids (22 patients) during the study period. Fifty-four of these patients (27 percent) continued to suffer symptoms of bleeding (38 patients) or bleeding and prolapse (16 patients) after three clinic assessments. Fifty-two of these 54 patients subsequently underwent Doppler-guided hemorrhoid artery ligation. Two other patients had stapled anopexy. After a median follow-up of 18 (range, 6-33) months, 12 of the 52 patients (23 percent) who underwent Doppler-guided hemorrhoid artery ligation have returned with recurrent symptoms of bleeding (6 patients) and/or prolapse (6 patients). Four patients with recurrent symptoms were treated by single quadrant hemorrhoidectomy, and the remaining eight underwent Doppler-guided hemorrhoid artery ligation with rectoanal repair. CONCLUSION: Doppler-guided hemorrhoid artery ligation reduces the need for conventional hemorrhoid surgery where rubber band ligation has been unsuccessful.

Rectal prolapse and rectal invagination

Solitary rectal ulcer, internal rectal intussusception, and complete rectal prolapse are a range of defaecatory disorders that may have a common aetiology, namely chronic straining. If the pelvic floor is weak, external prolapse is often complicated by faecal incontinence. Few patients, a lack of randomised trials, and difficulties in the interpretation of studies of anorectal physiology (the results of which often seem conflicting) have made the understanding of these disorders difficult. The basis for treatment is clear, however--patients who have symptomatic defaecatory disorders associated with an internal intussusception, or solitary rectal ulcer, or both should have a course of training of pelvic floor muscles, dietary advice, and should use fibre supplements as primary treatment. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms in above two thirds of patients. Defaecating proctography may be useful in assessing which patients may not benefit from operation. Operation is the primary treatment for external prolapse. The choice of surgical approach should be tailored according to the expertise available, the medical condition of the patient, and the presence or absence of pre-existing constipation or incontinence.

Preoperative staging of rectal cancer by magnetic resonance imaging remains an imprecise tool.

Following a curative resection for rectal cancer, local recurrence rates can vary between 3 and 32%.1 It is generally accepted that incomplete removal of the lateral spread of the tumour is the reason for most of these recurrences.2–6 The Norwegian Rectal Cancer Group found their overall local recurrence rate to be 7% in 686 patients studied.2 Involvement or near involvement of the circumferential resection margin (CRM) was found to correlate to the prevalence of local recurrence. The local recurrence rate increased to 22% when the CRM was involved (CRM < 1 mm) compared with 5% when negative (CRM > 1 mm). Additionally, it was observed that distant metastases occurred in 40% of patients with positive margins and 12% of patients with negative margins.2 The frequency of local recurrence was also greatly decreased where a tumour-free CRM of more than 1 mm could be obtained.3–5 The Swedish Rectal Cancer Trial separately found that preoperative radiotherapy significantly reduced local recurrence rates from 27% in controls to 11% in patients not undergoing TME6 but at the cost of increased morbidity.7 The Dutch Total Mesorectal Excision Trial8 confirmed that short-course preoperative radiotherapy decreased locoregional recurrence without excess mortality.6,7 There was an increased perioperative blood loss and perineal wound morbidity.9 The increased morbidity rate with preoperative radiotherapy is of concern, and therefore, radiotherapy should arguably be limited to instances where it is anticipated that local recurrence may occur. It could be reasonably limited to patients in whom an involved or close CRM is predicted.8,9 For those patients in whom a favourable tumour can be safely removed and oncologically cleared by surgery alone, the morbidity of radiotherapy may outweigh its possible small beneficial effect.10 Magnetic resonance imaging (MRI) is generally considered the gold standard for preoperative assessment of a rectal carcinoma. The phased-array coil is used as it is non-invasive and applicable to all rectal tumours.11 Among other investigative modalities, endorectal ultrasonography has a high degree of accuracy in tumour staging but cannot reliably estimate the CRM becuase of limited soft tissue contrast resolution and limited field of view (FOV).8 For preoperative rectal tumour staging, 90% has been proposed as an acceptable level of accuracy for a particular technique.12 MRI has been reported to be 94% accurate for the T stage and 85% for the N stage.13 The aim of this study was to assess the current level of accuracy of phased-array surface coil MRI in the preoperative evaluation and prediction of the CRM in rectal cancer. This study is a review of prospectively collected data. During the period January 2000 to June 2004, 77 consecutive patients under the care of one colorectal surgeon at the Royal Berkshire Hospital were diagnosed with rectal carcinoma. All patients underwent spiral computed tomography (CT) staging of their chest, abdomen and pelvis combined with pelvic MRI staging, followed by preoperative short-course radiotherapy and then to surgery within 48 h. For the purpose of this study, a rectal cancer was defined as an adenocarcinoma less than 15 cm from the anal verge at rigid sigmoidoscopy by the senior author with the patient examined in the left lateral position. The scans were carried out with a 1.0T whole-body Siemens Harmony System (Siemens, Erlangen, Germany) using a phasedarray surface coil. Axial T1-weighted turbo spin-echo images of the anatomic pelvis were obtained (340 mm FOV, 10 mm slice thickness, 2 mm intersection gap, 255 · 256 matrix size, 534/12 repetition time (rt) msec/time to echo (et) msec, three acquisitions, no fat saturation), followed by axial T2-weighted turbo spinecho images (340 mm FOV, 10 mm slice, 2 mm intersection gap, 255 · 256 matrix, 5000/120 rt/et msec, three acquisitions, no fat saturation). The T1 and T2 images were used to plan thin T2weighted axial and coronal images through the rectal tumour and surrounding perirectal tissues. Thinner section images were obtained at the discretion of the radiologist (using a 200 mm FOV, 3 mm slice thickness, 0.75 mm intersection gap, 4900/120 rt/et msec, 165 · 256 matrix, three acquisitions, no fat saturation). No bowel preparation, air insufflation or i.v. antispasmodic agents was used. The MRI scans were interpreted by one of four dedicated MRI radiologists. The following were assessed: site of rectal tumour with respect to the anal sphincter (high, mid, low), size of tumour (mm), invasion of the bowel wall, likelihood of involvement of the mesorectum or the CRM postoperatively and the presence of metastatic lymph nodes. Tumour confined to the bowel wall (T1 and T2) showed no evidence of extension of tumour signal beyond muscle of the bowel wall into perirectal fat. Tumour signal was interpreted as that of higher signal than the muscle of the bowel wall and of lower signal than the bowel submucosa. Invasion of the perirectal fat (T3 tumour) was assumed to have occurred with extension of tumour signal intensity through the muscle layer into the perirectal fat with a nodular margin. Spiculation within the perirectal fat alone was not used as a reliable criterion for the presence of extramural invasion as this can be caused by fibrosis.14 The mesorectal fascia, and hence the CRM, was defined as the fine linear structure enveloping the mesorectum, hypointense on T2-weighted and isointense on contrastenhanced T1-weighted images.8,14 The CRM was considered to be involved if tumour encroached to less than 1 mm from the mesorectal fascia. Invasion of adjacent organs (T4 tumour) was assumed if tumour signal intensity extended into an adjacent structure or viscus. Any isolated tumour deposit in the immediate perirectal space, measured to be within 3 mm of the bowel wall and with the same MRI signal as the primary tumour, was interpreted as extramural spread. Tumour deposits further than 3 mm from the bowel wall were assumed to represent metastatic spread. Tumour deposits of more than 3 mm in size were defined as involved lymph nodes even if no lymphoid tissue was present.15 The size criteria of †This paper was presented to a meeting of the Association of Surgeons of Great Britain and Ireland, April 2002, and the Tripartite meeting, Dublin, July 2005. ANZ J. Surg. 2008; 78: 194–198 doi: 10.1111/j.1445-2197.2007.04402.x

Surgical specialist registrars can safely perform resections for carcinoma of the rectum.

AIMnTo assess morbidity, mortality and cancer-related outcomes after supervised rectal resection for cancer by surgical specialist registrars (SpRs).nnnPATIENTSnA total of 205 consecutive patients (115 male; median age 64 years [range, 24-90 years]) under the care of six consultant surgeons, who underwent elective rectal resection of their rectal cancer between 1995-1999 were studied. The modified Dukes stages were A in 28 patients (13%), B in 47 (21%), C in 103 (51%), and D in 30 (15%).nnnRESULTSnSixty-eight patients (35 males) of mean age 64 years (range, 38-82 years) underwent supervised resection (60 anterior resections. 8 abdomino-perineal resections) by a SpR. Of these, 7 (10%) were modified Dukes stage A, 16 (22%) stage B, 37 (54%) stage C, and 8 (13%) stage D. Postoperative morbidity (SpRs 32% versus consultants 41%; P = 0.25) and mortality (SpRs 3% versus consultants 6%; P = 0.1) were comparable with consultant outcomes. Local recurrence rates (SpRs 9% versus consultants 9%; P = 0.5) and crude survival (SpRs 64% versus consultants 61%; P = 0.31) were also comparable after a median follow-up of 48 months (range, 24-72 months).nnnCONCLUSIONnOperative and cancer-related outcomes are not compromised by supervised SpR resections of rectal cancer in selected patients.

Subspecialisation and its Effect on the Management of Rectal Cancer

INTRODUCTIONnTo assess the impact of subspecialisation on surgical and oncological outcomes after rectal cancer surgery in a single surgical unit within a district general hospital.nnnPATIENTS AND METHODSnA total of 207 patients with rectal cancer treated surgically by two colorectal surgeons and four experienced general surgeons at the Royal Berkshire Hospital, Reading, England between January 1995 and December 1999 were studied. A retrospective case-note review of each patients personal details, operative and histological findings, their subsequent clinical progress and oncological outcomes, including 5-year survival were recorded.nnnRESULTSnIn the study group, 127 patients were treated by a colorectal surgeon and 80 by general surgeons. Pre-operative radiotherapy was more likely to be given to patients treated by a colorectal surgeon. Fewer permanent stomas were performed by colorectal surgeons. Postoperative morbidity, transfusion requirements, anastomotic leak rates and 30-day mortality were not significantly different. Tumour-involved circumferential resection margins, local recurrence rates and risk of distant metastases were similar between the two groups of surgeons.nnnCONCLUSIONSnColorectal subspecialisation has resulted in an increased use of pre-operative radiotherapy and fewer permanent stomas. No significant improvement in surgical or oncological outcomes after rectal cancer surgery have been observed.

A prospective audit of 300 consecutive young women with an acute presentation of right iliac fossa pain

INTRODUCTIONnA prospective study of 300 women of child-bearing age presenting with right iliac fossa pain was carried out to determine what proportion had appendicitis and whether active observation resulted in a delay in diagnosis to the detriment of the patient.nnnPATIENTS AND METHODSnData were prospectively collected for 300 consecutive women of childbearing age referred with right iliac fossa pain to general surgeons at a district general hospital.nnnRESULTSnAfter clinical assessment, 71 were discharged home immediately. Two others were found to be pregnant and 4 admitted to gynaecology. The remaining 223 women were admitted to the general surgical unit, 112 of whom underwent immediate appendicectomy. Of these, 97 had acute appendicitis. Two suffered deep infection and two had a superficial wound infection. A further decision to operate was made in 42 of 111 patients admitted for active observation, with 36 having acute appendicitis and 2 having a carcinoid tumour. Four had a wound infection. The average in-patient stay of those admitted for active observation and not operated on was 2 days (range, 1-4 days) compared with a length of stay of 2 days (range, 1-7 days) for those who underwent immediate appendicectomy.nnnCONCLUSIONSnMost women of child-bearing age who present with right iliac fossa pain do not have appendicitis. Those who do not have the classical features of appendicitis or peritonism can be safely managed by active observation.