S. M. Heah

Prospective randomised trial comparing ayurvedic cutting seton and fistulotomy for low fistula-in-ano

The aim of this study was to evaluate the role of ayurvedic setons in the treatment of low fistula-in-ano. One hundred and eight patients were randomised into either conventional fistulotomy (F) or ayurvedic cutting seton insertion (C). Endpoints investigated included time to wound healing and complications of surgery. Post-operative pain scores were measured daily using a visual analog scale. Anal function was compared using a continence score. Pre- and postoperative manometry and ultrasound were also performed. After exclusions, there were 54 patients in group F and 46 in group C. There were no differences in age, sex or follow-up duration between the two groups. Healing time was similar between the groups. Group C reported more pain following operation and on the first 2–4 postoperative days, but both groups experienced the same amount of pain subsequently. In conclusion, chemical seton was more painful than conventional fistulotomy in the first few days following surgery. However, there was no difference in time to wound healing, complications or functional outcome.

A prospective randomised study of drains in infra-peritoneal rectal anastomoses

Abstract. Although increasing evidence suggests that prophylactic drainage after intra-peritoneal colorectal anastomoses is unnecessary, drains for infra-peritoneal rectal anastomoses, where the leak rate is higher, are widely employed still. The aim of this study was to assess the effect of prophylactic drainage after anastomosis below the peritoneal reflection. All patients attending one specialist unit over an 8-month period for elective rectal cancer resection with an infra-peritoneal anastomosis were randomised to drainage or no drainage. The incidence of anastomotic leak and complications specific to the drain as well as other complications were compared. Fifty-nine patients were analysed (31 with drain). Twenty-five of the drained and 16 of the no-drain patients had a defunctioning stoma (p=ns). The groups were comparable for demographic data, operation and anastomotic height from the anal verge. There were three leaks (10%) in the drain group and five leaks (18%) in the no-drain group (p=ns). There were 2 (7%) patients in each group with a clinical leak. There were no specific drain complications and the incidence of other complications was similar in both groups. In conclusion, this study supports the contention that there is no difference in morbidity with or without the use of a drain for infra-peritoneal anastomoses.

Prospective, Randomized Trial Comparing Intraoperative Colonic Irrigation With Manual Decompression Only for Obstructed Left-Sided Colorectal Cancer

BACKGROUNDThis is a prospective, randomized, controlled trial comparing the outcome of intraoperative colonic irrigation with that of manual decompression for acutely obstructing colorectal cancers distal to the splenic flexure.METHODSAll patients admitted to our department from June 1999 to August 2002 with obstructing left-sided colorectal cancers were recruited. Patients were randomized intraoperatively and were excluded if deemed unsuitable for segmental resection and primary anastomosis. Twenty-five patients were randomized to receive colonic irrigation and twenty-eight to receive manual decompression. Perioperative parameters and outcome including mortality and anastomotic leak were recorded.RESULTSBoth groups of patients were comparable in terms of gender and age. The time taken for mobilization, decompression, and irrigation in the colonic irrigation group (median, 31 minutes) was significantly longer than that for the manual decompression group (median, 13 minutes) (P; = 0.0005). However, the total time of the operation was similar for both groups. Times for recovery of bowel function, of wound infection, and until discharge from the hospital were also similar. In the manual decompression group there were two cases of anastomotic leak (8 percent, 2/25) requiring reoperation but none (0/24) in the colonic irrigation group. However, this difference was not statistically significant.CONCLUSIONManual decompression of proximal colon without irrigation is as safe as colonic irrigation in one-stage surgical management of obstructing left-sided colorectal cancer.

Prospective, randomized trial comparing sigmoid vs. descending colonic J-pouch after total rectal excision.

AbstractPURPOSE: The aim of this study was to compare the bowel function of sigmoid vs. descending colonic J-pouches after ultralow anterior resection for rectal cancer. METHODS: A prospective, randomized trial was conducted from March 1998 to September 1999. Ninety-two consecutive patients undergoing ultralow anterior resection for cancers arising from 3 to 10 cm from the anal verge were recruited. Forty-eight patients were males; the mean ages (standard error of the mean) for patients with sigmoid and descending colon pouches, respectively, were 65.2 (3.1) years and 62.3 (3.1) years. A total of 46 patients were randomly assigned to each group. Two patients from each group were excluded; abdominoperineal resection was performed for two patients in the sigmoid pouch group and one patient in the descending pouch group. One patient in the descending pouch group had a transanal resection of a benign polyp. Dukes staging and use of postoperative chemoradiotherapy were statistically similar in both groups. All patients underwent a standardized ultralow anterior resection. A defunctioning loop ileostomy was used routinely. Anorectal physiology and bowel function questionnaires were performed at six weeks after ileostomy closure and again at 6 and 12 months after surgery. RESULTS: Median follow-up was 12 (range, 7 to 25) and 12 (range, 6 to 25) months, respectively, for sigmoid and descending pouch groups. Median tumor and anastomotic heights, time to ileostomy closure, operative time, and postoperative stay were statistically similar in both groups. There were no significant differences in stool frequency, incontinence, urgency, use of pads and antidiarrheals, sensation of incomplete evacuation, and anorectal physiology results between groups (P > 0.05). CONCLUSION: Pouches made from sigmoid or descending colon give similar bowel function after ultralow anterior resection for rectal cancers.

Prospective randomized study of bacteraemia in diathermy and stapled haemorrhoidectomy.

The incidence and consequences of bacteraemia associated with diathermy and stapled haemorrhoidectomy have not been studied previously.

Tumor size is irrelevant in predicting malignant potential of carcinoid tumors of the rectum

Abstract. The malignant potential and prognosis of rectal carcinoids are said to be related to tumor size. Our study assessed if size could predict the malignant potential and hence its management. All patients in the Department of Colorectal Surgery, Singapore General Hospital, who underwent surgery for rectal carcinoid tumors between February 1991 and September 2000 were analyzed. Twenty patients (11 men), median age 48 years (range, 33–77 years) were studied. Median follow-up was 40 months (range, 5–120 months). The median tumor diameter was 2.5 cm (range, 0.1–5.0 cm). Eleven patients underwent radical resection and 9 patients had local resection for a presumed benign tumor. Morbidity was 15% and postoperative death was 5%. Overall median survival was 24 months (range, 5–120 months). One patient had an anterior resection for rectal adenocarcinoma but had an incidental 0.1-cm carcinoid tumor near the resection margin which on histology was found to have carcinoid tumor metastasis to 2 out of 12 lymph nodes. In conclusion, tumor size cannot predict malignant potential as even small tumors (<1 cm) can be malignant. Accurate preoperative staging with radical surgery may be required.

Minilaparotomy left iliac fossa skin crease incision vs. midline incision for left–sided colorectal cancer

Abstract.BackgroundMidline laparotomies offer excellent exposure but are associated with increased postoperative pain and longer recovery. A minilaparotomy resection of leftsided colorectal cancers was studied as an alternative approach.Patients and methodsWe performed a case–control retrospective review of 280 randomly selected patients (140 midline incisions; 140 left skin crease incisions) who underwent elective, curative resection of left–sided colorectal cancers.ResultsPatients in both groups were of comparable age and sex. The left skin crease incision was shorter (median length, 13.5 cm) than the midline incision (median length, 20.0 cm). Median operation time was less in the left skin crease group (75 min) than in the midline incision group (105 min). Similar types of operations were performed, including left hemicolectomies, sigmoid colectomies, anterior resections and ultra–low anterior resections. Adequacy of resection was confirmed by histological analysis, with no involvement of margins. The median numbers of lymph nodes removed were comparable: 10 for the skin crease incision group and 12 for the midline incision group. Postoperative parameters for the skin crease incision group showed that feeding, ambulation, narcotic use and hospital stay were significantly better than the parameters in the midline group. Complications of intestinal obstruction were also reduced in the skin crease incision group.ConclusionsThe limited left skin crease incision provides adequate margins of clearance in colorectal cancers when compared to the midline incision, but has advantages of shorter operation time, earlier feeding and ambulation, and earlier discharge from hospital.

Hartmann's procedure vs. abdominoperineal resection for palliation of advanced low rectal cancer

In managing advanced low rectal adenocarcinomas in medically fit patients, surgical resection offers the best palliation. Tenesmus, bleeding per rectum, sacral pain, and sciatic pain are common complaints, which are not relieved by radiotherapy or fulguration. The most appropriate resection, however, remains controversial. Abdominoperineal resection is faster and simpler to perform but leaves behind a perineal wound with associated complications. Hartmanns procedure requires adequate mobilization below the tumor and may be technically more demanding but avoids a perineal wound. Therefore, an analysis of outcome in patients treated by Hartmanns procedurevs.abdominoperineal resection was made. METHOD: Fifty-four symptomatic patients with advanced rectal adenocarcinoma arising within a median of 5 (range, 4–8) cm from the anal verge treated between June 1989 and October 1995 were studied. Twenty-eight patients (17 males; mean age, 67.6±10.3 years) had Hartmanns procedure, and 26 patients (12 females; mean age, 68.8±8.3 years) were treated by abdominoperineal resection. Mean follow-up was 23.5 months (±17.5) and 18.6 months (±12.9) in Hartmanns procedure and abdominoperineal groups, respectively. RESULTS: Mean operative time was 138.4±26.7 minutes for Hartmanns procedure group and 124.6±27.1 minutes for the abdominoperineal resection group (P>0.05; not significant). Postoperatively, Hartmanns procedure group started oral intake at a mean of 2.3 days, and stomas were functioning at a mean of 3.1 days compared with 2.6 days for oral intake and 3 days for stoma functioning in the abdominoperineal resection group. Hartmanns procedure group was ambulant after a mean of 2.4 daysvs.a mean of 3.2 days in the abdominoperineal resection group. Postoperative abdominal wound infection occurred in 18 and 19 percent, respectively, in Hartmanns procedure and abdominoperineal resection groups. Forty-six percent of patients had perineal wound sepsis, and 38 percent had perineal wound pain in the abdominoperineal resection group. These complications were absent in Hartmanns procedure group. Postoperative stay was similar in both groups. CONCLUSION: We conclude that Hartmanns procedure offers superior palliation compared with abdominoperineal resection because it provides good symptomatic control without any perineal wound complications and pain.

Stapled hemorrhoidopexy for prolapsed piles performed with concurrent perianal conditions.

those who had lateral anal sphincterotomy undertaken concurrently. Of the 3 patients with fistula in ano, two had simple low anal fistulas that were laid open. SH was performed with the anastomosis proximal to the internal opening of the fistula. One of these patients had postoperative bleeding from the stapler line, which resolved with submucosae adrenaline injection. The other patient was readmitted 5 days after discharge from hospital for persistent perianal pain. This patient was treated symptomatically with simple oral analgesics and was discharged the following day. The third patient had an atypical horseshoe type of fistula in ano, with external openings at 3 and 9 o’clock positions and an internal opening at the 12 o’clock position. These tracts were laid open. However, the patient continued to have pain and fever postoperatively. This was attributed to a collection of pus at the base of the scrotum. Re-operation was done to drain the abscess. On the whole, 5 of 44 patients (11.3%) developed minor complications of bleeding, pain and localized abscess in the immediate postoperative period. None of these 44 patients developed major complications. The median pain score was 6 (range, 2–10) on the same day after operation, and 1 (range, 0–4) 2–4 weeks after surgery. All patients were fully continent and pain-free 8–12 weeks following surgery. The median overall satisfaction was 9 (range, 7–10). Pain scores and overall satisfaction for each of the concomitant conditions are shown in Table 1. There was an increase in the immediate postoperative pain when another procedure was undertaken to treat the concurrent perianal conditions. In view of this, surgeons must be prepared to counsel patients pre-operatively regarding the increase in pain after surgery. Our small study showed that SH can be performed in the presence of concurrent perianal conditions with minimal complications. However, the severity of postoperative pain C O R R E S P O N D E N C E

Which colorectal cancers are missed by double contrast barium enema

BackgroundThe relative merits of either barium enema or colonoscopy for investigating lower gastrointestinal tract symptoms is still unclear. We studied the value of double contrast barium enema (DCBE) as the initial evaluation modality. We reviewed our 10-year experience of double contrast enemas as read by consultant radiologists. The study also aimed to identify which lesions are usually missed.Patients and methodsWe reviewed clinical data for all patients who underwent DCBE within the 6 months prior to surgical resection of colorectal cancer between April 1989 and April 1999. Patient demographics and tumour characteristics were analysed for their effects on the likelihood of the lesions being missed at DCBE.ResultsThere were 706 patients included in the study, 54.2% were male and the mean age was 63.7 years (SEM=0.5 years). The site along the colon and rectum of tumours missed by DCBE corresponded with the frequency of tumour occurrence at each site. The overall rate of missed lesions was 4.1% (29 of 706 patients); these patients were found on subsequent endoscopy to harbour cancer. Tumours less than 3 cm in length and with lesser extent of circumferential involvement were more likely missed at DCBE (p=0.05 and p=0.01, respectively). Age, sex, and tumour grade and stage were not significant predictors of the likelihood of missed lesions. Of the 29 patients with missed lesions, 77.2% had a serum concentration of carcinoembryonic antigen (CEA) above the normal range (3.5 µg/l). The mean follow-up was 65.3 months (SEM=1.8 months). The overall survival for this series was 60.1%. The inaccuracy of the initial DCBE was not found to cause statistically significant differences in the stage of the tumour at diagnosis nor the overall survival of the patients in our series.ConclusionsSmaller cancers without circumferential involvement may be missed when DCBE is performed to evaluate lower gastrointestinal symptoms. Further evaluation by colonoscopy must be recommended when symptoms persist, especially in the context of a raised CEA level.