William Speake

Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER)

BackgroundExtra-levator abdominoperineal excision of the rectum (ELAPER) for low rectal cancer is used to avoid the adverse oncological outcomes of inadvertent perforation and a positive circumferential resection margin associated with the conventional APER technique. This wider excision creates a large defect requiring pelvic floor reconstruction, and there is still controversy regarding the best method of closure. The aim of this study is to present outcomes of biological mesh pelvic floor reconstruction following ELAPER.MethodsProspective data on consecutive patients having ELAPER for low rectal cancer at a single UK institution between October 2008 and March 2013 were collected. The perineum was reconstructed using a biological mesh and the short-term outcomes were evaluated, focusing particularly on perineal wound complications and perineal hernias.ResultsThirty-four patients were included [median age 62xa0years, range 40–72xa0years, 27 males (79xa0%)]. The median operative time was 248xa0min (range 120–340xa0min). The median length of hospital stay was 9xa0days (range 4–20xa0days). There were three perineal complications (9xa0%) requiring surgical intervention, but no meshes were removed. There were no perineal hernias. The median length of follow-up was 21xa0months (range 1–54xa0months). The overall mortality was 9xa0% from distant metastases.ConclusionsOur series adds to the increasing evidence that good outcomes can be achieved for pelvic floor reconstruction with biological mesh following ELAPER without the additional use of myocutaneous flaps. The low serious complication rate, good outcomes in perineal wound healing and the absence of perineal hernias demonstrates that this is a safe and feasible procedure.

Closure of loop ileostomy: potentially a daycase procedure?

BackgroundFour thousand four hundred and twenty-seven ileostomy closures were performed in the UK in 2008–2009, (35,432 bed days). None were recorded as being performed as a daycase procedure. Our aim is to evaluate the morbidity and mortality associated with this procedure and to investigate whether daycase surgery is feasible.MethodPatients having closure of loop ileostomy were identified retrospectively from May 2005 to July 2010. The primary surgery, method of ileostomy closure, length of hospital stay and early (≤30xa0days) or late (>30xa0days) complications were recorded.ResultsA total of 138 patients were evaluated. The median age was 63 (17–83) years and 64% were male patients. The primary surgery was predominantly anterior resection (74%). Median time from initial surgery to reversal was 37 (1–117) weeks. The median length of hospital stay was 4 (1–39) days. Applying a 23-h discharge protocol to our results excluded 18 patients categorised as ASA3. Ninety-six patients (80%) met the discharge criteria for a potential 23-h hospital stay. The expected readmission rate within 30xa0days of surgery was 12% (nxa0=xa014). 85 patients (71%) did not suffer an early complication. There were 35 early complications (30%), 10 general and 25 specific to the procedure, but serious only in 5%. There were no deaths in the eligible patients.ConclusionClosure of loop ileostomy in our series is safe, with a low serious morbidity rate. It may be feasible to perform reversal of ileostomy as a daycase/23-h stay. We intend to implement a 23-h stay for reversal of ileostomy.

Day-case closure of ileostomy: feasible, safe and efficient

Over 5000 loop ileostomy closures were performed in the UK in 2013 with a median inpatient stay of 5 days. Previously we have successfully implemented a 23‐h protocol for loop ileostomy closure which was modified for same‐day discharge. We present our early experience of day‐case loop ileostomy closure.

Twenty-three-hour stay loop ileostomy closures: a pilot study

BackgroundIn UK in 2010–2011, 4,463 ileostomy closures were performed (35,442 bed days) with a median inpatient stay of 5xa0days (Hospital Episode Statistics data). This seems anomalous when there are reports of 23-h stay colectomies. We present our early experience of 23-h discharge for loop ileostomy closures.MethodsA specific patient journey/pathway for 23-h discharge following loop ileostomy closure was implemented at a single UK institution between August 2011 and April 2012. Follow-up was by telephone contact 24–48xa0h postdischarge and by routine outpatient appointment, and patients were also provided with a 24-h contact point in case of emergency.ResultsTwenty-three patients were included (18 male patients; median age, 63xa0years; range, 28–78xa0years). Fifteen were discharged within 23 h. The remaining 8 patients were all discharged within 48xa0h of surgery. Four patients were readmitted with superficial wound infection (1), slight wound discharge (1), Clostridium difficile diarrhoea (1) and an anastomotic leak 8xa0days after surgery (1). Median length of follow-up was 3xa0months (range, 1–10xa0months).ConclusionsA specific 23-h discharge protocol for loop ileostomy closures is feasible and safe. Improved primary care and out-of-hours hospital support would have prevented both minor wound complications requiring readmission. The anastomotic leak presented at postoperative day 8 and would have occurred in the community even if a standard protocol was used. Additional patient information and support via stoma care have been introduced to build on our experience, and 23-h stay has been introduced as standard care.

Anyone for TAMIS

A 64-year old lady underwent a rectal polypectomy for a postero-lateral polyp at 5 cm from the anal verge. Histology demonstrated a focus of adenocarcinoma (Haggit level 3). She went on to undergo excision of the polyp scar using Trans-Anal Minimally Invasive Surgery (TAMIS), a novel technique dubbed a hybrid between Transanal Endoscopic Microsurgery (TEM) and single port laparoscopy (Figs. 1, 2, 3–4). Mucosal resection of

Diagnostic yield and economic implications of endoscopic colonic biopsies in patients with chronic diarrhoea

Aimsu2002 Random colonic biopsies are recommended to exclude microscopic colitis in patients with chronic diarrhoea especially when mucosa is macroscopically normal at endoscopy. This study aimed to assess the clinical outcome and economic impact of such a policy in an unselected group of patients with macroscopically normal mucosa.

One-third of patients fail to return to work 1 year after surgery for colorectal cancer

AbstractBackgroundnAchieving full recovery after colorectal cancer surgery means a return to normal physical and psychological health and to a normal social life. Recovery data focusses on time to discharge rather than longer term functionality including return to work (RTW). We aim to assess return to normal holistic function at 1xa0year after colorectal cancer surgery.MethodQuestionnaires were created and dispatched to 204 patients who had undergone surgery with curative intent for colorectal cancer, in 2011–2012, in a single teaching hospital.ResultsResponse rate was 75xa0% (153/204), 82xa0% (129/157) for open surgery (OS) and 51xa0% (24/47) for laparoscopic surgery (LS). Median age was 68 (48–91) years for OS and 65 (36–84) for LS. Eighty-four per cent of patients felt ‘ready’ and 95xa0% had adequate pain control upon discharge (no difference between groups). LS reported earlier ‘return to full fitness’ (1–3xa0months) than OS (>6xa0months; Mann–Whitney U, pxa0<xa00.05). Recovery from LS was ‘better than expected’ compared to OS ‘worse than expected’ (Mann–Whitney U test, pxa0<xa00.05). Forty-nine patients were employed preoperatively and 61xa0% (nxa0=xa030) returned to work. RTW was more frequent after LS (Chi-square test, pxa0<xa00.05). Length of time to RTW was significantly less after LS [44 (6–84) days] than OS [71 (14–252) days] (t test, pxa0<xa00.05). Levels of self-employment were equal between groups.ConclusionsnOne-third of patients failed to RTW at 1xa0year post-surgery. Patients having LS returned to full fitness faster, felt recovery was shorter and returned to work earlier than OS. We must invest more in managing expectations and provide better post-discharge support to improve RTW.

Clostridium difficile enteritis in a patient after total proctocolectomy

Clostridium difficile infection is associated with antibiotic therapy and usually limited to the colonic mucosa. However, it is also a rare cause of enteritis, with only a few cases reported in the literature. In the present report, the case of a 30-year-old woman with Clostridium difficile enteritis who previously had a panproctocolectomy with end ileostomy for severe ulcerative colitis is described. Previously reported cases of Clostridium difficile enteritis are also reviewed. Previous antibiotic therapy had been present in all cases and appears causative, major colonic resection is a precipitating factor. Small bowel Clostridium difficile infection should be considered in any patient with ileostomy flux/diarrhoea after major colonic surgery. If recognised early and treated aggressively the high mortality associated with Clostridium difficile enteritis may be avoided.

The ‘cut and push’ technique: is it really safe?

Percutaneous endoscopic gastrostomy (PEG) feeding is routinely used as an endoscopic and effective method for providing enteral nutrition in those whose oral access has been diminished or lost. One technique for removal of the PEG is cutting the tube at the skin level and allowing the tube and internal flange to pass spontaneously. This is known as the ‘cut and push’ method. Several studies have concluded that the ‘cut and push’ method is a safe and cost-effective method. This case demonstrates a rare cause of small bowel obstruction following the ‘cut and push’ method for PEG replacement, with only a few other cases been reported. This method of removal should be avoided in patients with previous abdominal surgery. It is important that the PEG flange is retrieved endoscopically or an alternative PEG tube (designed to be completely removed through the skin) is used to prevent this complication occurring in such individuals.

Large bowel obstruction due to sesame seed bezoar: a case report

We report a case of a 79 year old man with a known benign anastomotic stricture presenting with large bowel obstruction. At laparotomy the obstruction was found to be caused by a large sesame seed bezoar. Seed bezoars are well known to cause impaction in the rectum but have never been previously reported to cause large bowel obstruction. We recommend that patients with known large bowel strictures should be advised not to eat seeds as this could ultimately lead to obstruction, ischaemia or perforation.