Yik-ng Ho

Stapled hemorrhoidectomy—cost and effectiveness. randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months

PURPOSE: Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique. METHODS: A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique=62; stapled hemorrhoidectomy=57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs. RESULTS: Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9)vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4)vs. 2.6 (0.4);P<0.005) at two weeks, and analgesic requirements were more for up to six weeks (P<0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent)vs. 19 (33.3 percent);P<0.05) and pruritus (27 (43.5 percent)vs. 9 (15.8 percent);P<0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent)vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8)vs. 17.1 (1.9) days;P<0.05), but the total costs incurred were less (

A simple and effective treatment for hemorrhagic radiation proctitis using formalin

921.17 (16.85)vs.

Transanal approach to rectocele repair may compromise anal sphincter pressures

1,283.09 (31.59);P<0.005). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial.

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were Treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42–73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9–46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1–12 months). The median number of units of blood transfused previously per patient was four (range, 2–32). The time taken for formalin therapy was 20 minutes (range, 10–70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1–6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.

Anal sphincter injuries from stapling instruments introduced transanally

PURPOSE: This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation. METHOD: Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later. RESULTS: All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n=19; after, n=3;P=0.001), need to digitate per vagina (before, n=16; after, n=0;P=0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2);P=0.004), and laxative requirements (before, n=7; after, n=0;P=0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P<0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P<0.05) after operations. There was no other morbidity. CONCLUSION: Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.

Prospective, randomized trial comparing pain and clinical function after conventional scissors excision/ligation vs. diathermy excision without ligation for symptomatic prolapsed hemorrhoids

The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 ± 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 ± 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 ± 2.8 vs. 49 ± 1.4/week; p<0.05) and less soiling at passing flatus (38% vs. 73.7%; p<0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 ± 0.4 vs. 8 ± 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p<0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch. Après résection antérieure du rectum ultra-basse, le réservoir colique en J (POUCH) fonctionne mieux que l’anastomose coloanale sans réservoir (STRAIGHT), mais il existe peu d’études avec un suivi à long terme. Cette étude randomisée, contrôlée, compare l’évolution fonctionnelle et la manométrie anale ainsi que l’évaluation barostatique dans ces deux groupes de patients pendant une période de deux ans. Quarante-deux patients consécutifs ont été inclus, dont 19 STRAIGHT (17 hommes; âge moyen 62,1 (ETS: 2,3) ans) et 16 POUCH (11 hommes; âge moyen 61,3 (3,2) ans). Quatre patients sont décédés de métastases (et deux ont émigré), mais il n’y avait aucune morbidité ou de récidive locale. A 6 mois, les patients POUCH allaient significativement moins fréquemment à la selle (32,9) (2,8) vs. 49 (l,4)/semaine; p<0,05) et avaient moins de souillures lorsqu’ils passaient des gaz (38% vs. 73,7%; p<0,05). A 2 ans, les résultats des deux groupes se sont améliorés avec aucune différence en ce qui concernait la fréquence des selles (7,3 (0,4) vs. 8 (0,2)/semaine) ou la souillure en passant des gaz (38% vs. 53%). Les problémes de défécation sont restés minimes dans les deux groupes. Les pressions de contraction anale étaient significativement perturbées dans les deux groupes, jusqu’à deux ans (p<0,05). Le volume rectal maximal tolérable et la compliance n’étaient pas significativement différents entre les deux groupes. Selon les résultats de la barostatique phasique on a mis en évidence une perturbation à 6 mois mais avec une récupération à 2 ans, suggerérant que la récupération postopératoire de nerfs sympathiques afférents joue peut-être un rôle dans la récupération fonctionnelle. En conclusion, à 6 mois, la fréquence des selles et de l’incontinence sont moindres après une anastomose POUCH, mais après 2 ans, les patients ayant une anastomose STRAIGHT ont des résultats similaires. Néanmoins, cet avantage fonctionnel inhérent à l’utilisation de l’anastomose avec réservoir en J ne demande qu’un minime effort de plus et l’intervention se complique peu. Existen pocos trabajos que valoren los resultados funcionales tardíos de la bolsa en J de colon (POUCH) con la anastomosis termino-terminal colorrectal, tras resecciones anteriores, muy bajas, de recto. En este estudio controlado y randomizado, se comparan, tras un seguimiento de 2 años, los resultados funcionales, la manometría anal y la barestesia rectal en dos grupos de pacientes tratados quirúrgicamente, con una de las dos técnicas mencionadas. La población estudiada comprende 42 pacientes; 19 tratados mediante anastomosis directa (grupo STRAIGHT) de los que 17 fueron hombres con una edad media de 62.1 (SEM: 2.3) años; el otro grupo (POUCH) comprende 16 pacientes de los que 11 fueron hombres con edad media de 61.3 (3.2) años. 4 enfermos murieron como consecuencia de diseminación metastásica y 2 emigraron. No se registró morbilidad quirúrgica alguna, ni recidivas locales. A los 6 meses, los enfermos del grupo POUCH presentaban un número significativamente menor de deposiciones [32.9 (2.8) vs. 49 (1.4)] por semana (p<0.05). y al ventosear dejan escapar menos materia fecal (38% vs 73.7%; p<0.05). A los 2 años, los pacientes de ambos grupos mejoraron sin que existieran diferencias ni en el número de deposiciones [7.3 (0.4) vs. 8 (0.2)], ni al mancharse al ventosear (38% vs. 53%). Los problemas de defecación fueron mÍnimos en ambos grupos. Las presiones anales al intento de defecar mejoraron significativamente en ambos grupos, a partir de los 2 años de la intervención (p<0.05). El volumen máximo tolerable y la “compliance” rectal fue igual en los dos grupos. La sensibilidad rectal, detectada mediante un programa fásico barestésico, mejora a los 6 meses y se recupera a los 2 años de la operación, lo que sugiere que en la recuperacion postoperatoria, los nervios simpáticos aferentes no resecados, desempeñar un importante papel en la recuperación funcional. Conclusión: el número de defecaciones y la incontinencia son menores en el grupo POUCH, hasta que transcurren 6 meses de la operación, pero tras un période de adaptación de 2 años, los resultados en el grupo POUCH y en el grupo STRAIGHT son semejantes. A pesar de ello la recuperción funcional es más rápida con la bolsa en J de colon (POUCH) y este mayor confort para los enfermos se puede alcanzar con un minimo esfuerzo añadido y sin complicaciones.

High preoperative serum carcinoembryonic antigen predicts metastatic recurrence in potentially curative colonic cancer: Results of a five-year study

PURPOSE: Injury sustained from the transanally introduced stapling technique was assessed by comparison with biofragmentable anastomotic ring anastomosis, which excluded anal manipulation. METHODS: A randomized, controlled trial was conducted on consecutive patients undergoing sigmoid colectomy (where pelvic nerve injury was avoided). A bowel function questionnaire was administered six months after surgery. Anorectal manometry and endoanal ultrasonography were performed preoperatively and at six months postoperatively. The observers were blinded to the randomization. RESULTS: There were 18 patients in the transanally introduced stapling technique group and 17 patients in the biofragmentable anastomotic ring group, with no differences in age, gender, Dukes staging, and follow-up. Three of the transanally introduced stapling technique patients had occasional liquid soiling, which was absent in biofragmentable anastomotic ring patients. Mean change in resting anal pressures was also significantly impaired when compared with patients with biofragmentable anastomotic ring (P=0.007). Endosonographic internal sphincter fragmentation was found in five transanally introduced stapling technique patients but none after biofragmentable anastomotic ring anastomosis (P=0.046). Internal sphincter fragmentation was associated with the impaired resting pressures (P=0.007). External sphincter deficiencies were found after transanally introduced stapling technique in two patients (biofragmentable anastomotic ring = 0), and these were associated with the soiling (P=0.005). CONCLUSIONS: The transanally introduced stapling technique may result in anal sphincter defects and impaired anal pressures when assessed at six months of follow-up.

Randomized controlled trial of primary fistulotomy with drainage alone for perianal abscesses

Forty-nine consecutive patients with symptomatic prolapsed hemorrhoids were prospectively randomized for conventional scissors excision with ligation (Group A; n = 16) or diathermy excision without ligation (Group B; n = 33). The median time taken to complete the procedure was 20 minutes (range, 10–40 minutes) and 10 minutes (range, 5–35 minutes) in Groups A and B, respectively (P<0.05). Length of hospital stay was similar in both groups, with a median of three days and a range of two to five days. The median length of follow-up was 35 weeks (range, 20–50 weeks) and 35 weeks (range, 20–51 weeks) for Groups A and B, respectively. There was no statistical difference in the severity of postoperative pain between the two groups. The use of postoperative oral analgesics was significantly lower in Group B (P<0.02), but there was no significant difference in the demand for intramuscular or topical analgesics. Diathermy excision of hemorrhoids is significantly faster than scissors excision, there is less bleeding, the vascular pedicles need not be ligated, and there is significant reduction in the requirement for oral analgesics postoperatively without any increase in early or late postoperative complications.

Bowel function survey after segmental colorectal resections.

INTRODUCTION: Serum carcinoembryonic antigen is used mainly for tumor follow-up to detect recurrence of colonic cancer. However, raised preoperative carcinoembryonic antigen levels may be helpful for the identification of understaged cases and of patients meriting more intensive preoperative and postoperative diagnostic workup. METHODS: From a prospectively collected database, the data on 261 patients who had curative colonic carcinoma with a minimal follow-up of five years and who had preoperative carcinoembryonic antigen levels assessed were retrieved and analyzed. Outcome parameters were local and/or distant recurrence and time to recurrence. These parameters were correlated with Dukes staging and preoperative carcinoembryonic antigen levels. RESULTS: The cumulative diseasefree survival of patients with a preoperative carcinoembryonic antigen level within the normal range was significantly better than that of those whose carcinoembryonic antigen was 5 ng/ml or more (P=0.001). No patient with carcinoembryonic antigen levels less than 1 ng/ml developed metastatic recurrence. Twenty-three percent of all patients with a raised carcinoembryonic antigen above 5 ng/ml compared with 2.1 percent of patients with carcinoembryonic antigen below 5 ng/ml developed a metastasis at two years. At five years, these figures were 37.2 percent and 7.5 percent, respectively. Dukes staging and carcinoembryonic antigen levels were found to be directly correlated (P<0.001) when all patients were included. Carcinoembryonic antigen of more of 15 ng/ml was found to be a significant adverse prognostic indicator for disease-free survival irrespective of Dukes staging (P<0.02). Raised carcinoembryonic antigen levels predicted distant metastatic recurrence (P<0.001) but did not predict local recurrence (P=0.72). CONCLUSIONS: High preoperative carcinoembryonic antigen levels above 15 ng/ml predicted an increased risk of metastatic recurrence in potentially curative colonic cancer and may indicate undetectable disseminated disease. Preoperative carcinoembryonic antigen levels predict understaging and the possibility of distant recurrence. Such patients may therefore be selected for adjuvant therapy where indicated. Therefore, carcinoembryonic antigen is complementary to conventional Dukes staging for the prediction of recurrence and survival.

Randomized, controlled trial of low molecular weight heparin vs. no Deep vein thrombosis prophylaxis for major colon and rectal surgery in Asian patients

PURPOSE: Primary fistulotomy may be advantageous for perianal abscesses because unlike ischiorectal abscesses, fistulas are more commonly found and can be laid open with full preservation of the external anal sphincters. Therefore, a randomized, controlled trial was conducted to compare primary fistulotomy with incision and drainage alone, specifically for perianal abscesses. METHODS: Fifty-two consecutive patients (43 males; mean age, 40 (standard error of mean, 2) years) with perianal abscesses were randomized to treatment by either incision and drainage (controls; N=28) or fistulotomy (N=24). Patients were followed up clinically for a mean of 15.5 (standard error of the mean, 0.7) months. Anorectal manometry was also performed before, six weeks, and three months after surgery. RESULTS: Persistent fistulas developing after surgery were significantly more common after incision and drainage (N=7; 25 percent) than after fistulotomy (N=0;P=0.009). One patient in each group was also found to have a residual abscess, which required repeat drainage. All patients remained fully continent. The anal pressures after incision and drainage and fistulotomy were not significantly different. Operative time, hospital stay, and time for the wound to heal completely were the same in both groups. CONCLUSIONS: Primary fistulotomy at the time of drainage for perianal abscesses results in fewer persistent fistulas and no added risk of fecal incontinence.