Colorectal

Enhanced recovery following colorectal resection is a set of interventions which, when combined, lead to early return of
gut function, fewer complications and a shorter length of stay. It divides the patient’s journey into stages and ensures the
surgical stress inflicted onto the patient is minimised and normalisation can occur as soon as possible. There has been much
research into this new and advancing field with several meta-analyses confirming its benefit.

Colorectal cancer (CRC) is a very frequently diagnosed pathological entity, registering an elevated incidence rate each year. CRC stems from both a genetic and an environmental background, exhibiting divergent molecular and biological phenotypes, and rendering its therapy, follow-up and prognosis a demanding task. Telomerase, a complex consisting of the catalytic protein human telomerase reverse transcriptase (hTERT) and the mRNA template hTERC, is related to the preservation of telomere length (TL). A wide range of studies suggest that hTERT also partakes in signalling pathways relevant to proliferation and apoptosis. Thus, the potent role of telomerase as a biomarker for CRC behaviour emerges as a reasonable inquiry.

Aim  Most medical teaching is still delivered by traditional face-to-face interaction. E-learning has the potential benefit of instilling deeper learning of topics by virtue of repeated and convenient access to content presented in a range of media. We aimed to evaluate objectively the benefit of educating medical students on a common surgical topic (haemorrhoids), through a website and podcast package vs a traditional lecture.Method  Baseline knowledge was established by a questionnaire given to two different groups of third-year medical students starting their first clinical attachment. Group A (n = 73) was given a lecture and group B (n = 75) was asked to use a website containing text and pictures augmented by a podcast. Students were reassessed using the same preintervention questionnaire, and satisfaction was acquired from details given in a feedback form.Results  There was no difference in knowledge between the two groups at baseline. Both groups demonstrated significant gains in knowledge after intervention (P < 0.0001). Group B (Web/podcast) showed a significantly greater increase in knowledge (P < 0.05) than group A (lecture). Preintervention subjective assessment of knowledge rated by the students showed no difference between the groups. Both groups of students were equally satisfied with the educational method.Conclusion  E-learning supplemented with a podcast results in greater knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching. Using augmented Web-based educational tools reduces demands on teaching time with no decrease in quality for selected parts of the curriculum.

Collagen and blood vessels of the urethral submucosa of ovariectomized rats were studied following 28 daily subcutaneous injections of 17-ß estradiol (n=6, group 1), medroxy-progesterone acetate (n=6, group 2), both drugs (n=6, group 3) or vehicle (n=6, control) and after sham surgery without castration or injection (n=6). Investigations included the immunohistochemistry of estrogen and progesterone receptors and collagen fibres, Western blot analysis of collagen types I and III and counting periurethral vessels by light microscopy. Our results showed positive immunostaining with estrogen, progesterone and collagen types I and III in all samples. Collagen type I and III levels were lower in the controls than in the sham group. The other groups showed increases (2>3>1) over the controls with a relatively higher increase in type III. The type I/III collagen ratio progressively decreased (control>1>2>3) below sham levels. The mean vessel count was significantly lower in control than in sham animals (PP=0.04). Our results indicate that estrogen and progesterone, alone or in combination, have an effect on collagen types I and III, and that estrogen has an effect on blood vessels of the urethral submucosa in female rats.

This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included. Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy. There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic di...

The aim of this study was to review the recent results of ileal pouch-anal anastomosis (IPAA) in elderly patients compared with younger patients. Retrospective evaluation was carried out based on a prospective Institutional Review Board approved database of patients who underwent IPAA from 2001 to 2008. Patients aged ≥ 65 years were matched with a group of patients aged &amp;lt; 65 years by gender, date of procedure, diagnosis and type of procedure performed. Preoperative and intra-operative data and early postoperative complications were obtained. Thirty-three patients (22 women), 32 with mucosal ulcerative colitis, were included in each group. The elderly group had a mean age of 68.7 years, body mass index of 27 kg/m², duration of disease of 17.4 years, high American Society of Anesthesiologists (ASA) score and high incidence of comorbid conditions (87.9% had one or more). Dysplasia and carcinoma were the indication for the surgery in more than 50% of patients, followed by refractory disease (24.4%). The matched younger group had a mean age of 36.9 years, body mass index of 25.4 kg/m², shorter duration of disease (8.1 years; P = 0.001), lower ASA score (P = 0.0001) and lower comorbidity (42.4%; P = 0.0002). Operative data were similar for both groups. The elderly group had a higher rate of rehospitalization for dehydration (P = 0.02). Other medical complications (30 vs 27%) and surgical postoperative complications (33 vs 24%) were similar for both groups. The long-term function and complications were comparable for the groups. Elderly patients who underwent IPAA had more comorbid conditions than younger patients. Except for rehospitalization for dehydration, medical and surgical postoperative complications were not different in the two groups.

Pyoderma gangrenosum is a rare idiopathic skin disorder associated with other diseases, including inflammatory bowel disease. The commonest site is the skin, but sometimes it can occur in the parastomal region. Most of these cases respond to treatment with systemic corticosteroids and cyclosporin or local Kenalog injections. The following are two cases of parastomal pyoderma in patients not responding to the standard measures. These patients were treated with topical tacrolimus. These patients showed dramatic improvement in one week with complete resolution and re-epithelialization of skin within two weeks. Pyoderma gangrenosum is a difficult problem to manage and its early resolution is important. In these two reported cases, the improvement was dramatic, therefore topical tacrolimus should be considered early in the management.

Objective  The study was designed to compare the early postoperative results of the commonly used two surgical flap procedures in pilonidal disease: Karydakis and Limberg.Method  One hundred patients were randomized into two groups and standard Limberg or Karydakis procedures were performed. All had primary sinus orifices. Infected cases and the ones with secondary orifices over 2 cm distant from primary were excluded. Data were recorded concerning complications, need for analgesia and wound dressing, periods of time off work and off driving. Patients were asked to classify their first defecation manner after the operation and also pain according to a Visual Analogue Scale with range of 1–10.Results  There was a significantly higher wound infection rate in the Karydakis group than in the Limberg group (13/50 and 4/50 respectively). This also resulted in significantly higher values for wound dressings and need for analgesia. The time off work and off driving and also the Visual Analogue Scale scores were not significantly different between the two groups.Conclusion  Both procedures can be safely performed in pilonidal disease with a standard length of stay in hospital and a similar loss of productive power. However, the Karydakis flap seems to have a significant higher infection rate and this probably increases the cost.

Background  Histopathological studies have shown the presence of oestrogenic receptors in the anal sphincter, which presumes a role in muscular trophism for circulating oestrogens. This could explain the increase in faecal incontinence (FI) in postmenopausal women.Objective  To evaluate the effect of topical oestrogens (TE) in controlling symptoms of FI in postmenopausal women.Hypothesis  The application of TE in postmenopausal women with FI improves continence.Method  We performed a prospective double-blind randomized trial applying TE to the anal mucosa in postmenopausal women with FI. Study period: 2005–2006. The patients were randomized into two groups: I – topical estriol, II – placebo. In both groups, the ointment was applied three times daily for a period of 6 weeks. We compared Wexner’s FI score and the FI quality of life scale, before commencing and after 6 weeks of application.Results  In this period we evaluated 36 patients. Average age: 67 years (48–84). Group I: 18 patients and group II: 18 patients, one patient was excluded. Wexner’s FI score in group I was 11 (5–18) and 7 (0–19) with pre- and postapplication respectively (P = 0.002). Wexner’s FI score in group II was 12 and 9 with pre- and postapplication respectively (P = 0.013). When we compared the results between both groups, this was not statistically significant (P = 0.521).Conclusion  There is improvement of continence in both groups that had the ointment applied; nonetheless this study could not show that TE improves FI more than a placebo does.

Objective  The reduction in tumour stage induced by full course radiotherapy plus chemotherapy is apparent from histological changes. The purpose of this study was to determine the rate of complete pathological response and to evaluate the prognostic value for disease free survival (DFS) and disease specific survival (DSS) of the response. The relation between pretreatment variables (age, gender, stage, tumour height and [carcinoembryogenic antigen (CEA)] and postsurgical variables was compared to the pathological response.Method  A total of 119 patients with stage II or III rectal cancer underwent surgery 6 weeks after neoadjuvant treatment. Group A included patients with a complete or good pathological response (Mandard grade I–II) and group B patients with a poor response (Mandard grade III–IV–V).The pretreatment endo-rectal ultrasound scan stage was compared with histopathology stage of the resected specimen. DFS and DSS were compared using the log-rank test.Results  All 119 patients (mean age 67.9 years, 83 males) underwent resection. The tumour was located in the upper, middle and lower third of the rectum in 11, 51 and 57 patients. 88 patients had a low anterior resection, 28 patients abdomino-perineal resection and three a Hartmann’s operation. There was no postoperative death. The circumferential margin (CM) was involved in 10%. A complete pathological response was observed in 17 (14.2%) patients. Thirty-six (30.2%) patients had a group A and 83 a group B response. Group A showed DFS to be significantly higher than group B (log rank: P = 0.007). The DSS rate was not significantly different between the two groups (log rank P = 0.113). Down-staging was not related with DFS. No relation was found between pretreatment variables and response. A good pathological response was related to a lower rate of permanent colostomy but not with CM involvement or the number of lymph nodes.Conclusion  Tumour regression of grades I or II was a good indicator of DFS in locally advanced rectal cancer, treated by neoadjuvant chemotherapy and radiotherapy. Patients with a high regression grade were associated with a lower incidence of definitive stoma formation. The regression grade was shown to be a better prognostic factor than down-staging.

Previous analyses of non-prospectively randomized trials have suggested that early oral postoperative feeding might be a benefit unique to laparoscopic surgery. However, some authors have indicated that early feeding can be tolerated by the majority of patients after elective open surgery. Aim: This prospective randomized study was undertaken to assess whether the time prior to oral intake of food after laparoscopy-assisted surgery is shorter than that after standard laparotomy. Methods: This trial included 40 patients who were divided randomly into two groups before operation. Group I included 20 patients (mean age, 52 years; range , 15 – 77 years) who underwent a laparoscopy-assisted colon or rectal procedure (LAP). Group II consisted of 20 patients (mean age, 56 years, range, 41 – 74 years) who underwent surgery with a standard midline incision (SMI). On the evening after surgery, patients were allowed clear liquids ab libitum. This regimen was continued until the first postoperative day at which time they could elect to start eating a regular diet. If a patient had two episodes of vomiting, a nasogastric tube was inserted. Results: Five laparoscopic procedures were converted to SMI because of adhesions (25%) and an equal number of patients was excluded from the group that was treated in the traditional manner. Therefore, only 30 patients were included in the analysis. There were no deaths in this trial. Complications appeared in four of the patients in the LAP group and in two of the patients in the SMI group (no significant difference). There were no statistically significant differences between the two groups in terms of the ability to tolerate the early oral intake of food, in the frequency of vomiting or in the incidence of insertion of a nasogastric tube. The time to the first bowel movement was 5.4 days in LAP and 5.5 days in SMI, and the difference was not significant. Conclusion: This study invalidates the claim by laparoscopic surgeons that earlier oral intake of food is tolerated by their patients than by patients who undergo standard procedures. Des études randomisées non prospectives ont suggéré que la reprise précoce de l'alimentation orale peut être un bénéfice particulier à la chirurgie laparoscopique. Certains auteurs ont indiqué que la reprise précoce de l'alimentation orale peut être bien tolérée par la plupart des patients après chirurgie élective ouverte. Cette étude prospective randomisée a été entreprise pour déterminer si la reprise orale de l'alimentation après chirurgie laparoscopique peut être plus précoce qu'après une laparotomie standard. Quarante patients ont été inclus dans cette étude et ont été divisés de manière randomisée en deux groupes avant chirurgie. Le groupe 1 comporte 20 patients (15 à 77 ans, moyenne d'âge 52 ans) qui ont subi une résection colique ou rectale laparoscopique (LAP). Le groupe II comporte 20 patients (41 à 74 ans, moyenne d'âge 56 ans) qui ont subi une chirurgie par une incision médiane standard (SMI). Le soir de l'intervention chirurgicale, les patients ont été autorisés à boire librement. Ce régime a été continué le premier jour postopératoire à partir duquel les patients pouvaient débuter une alimentation normale. Si un patient présente deux épisodes de vomissements, une sonde naso-gastrique a été mise en place. Cinq interventions laparaoscopiques ont dûêtre converties en chirurgie ouverte en raison d'adhérences (25%) et un nombre égal de patients ont été exclus du groupe qui a été traité de manière traditionelle. En conséquence, 30 patients ont été inclus dans l'analyse. Aucun décès n'est à déplorer. Quatre complications sont survenues chez des patients du groupe laparoscopique et deux dans le collectif des patients ayant subi un chirurgie ouverte (pas de différence statistique significative). Il n'y a pas de différence statistique significative entre les deux groupes en ce qui concerne la tolérance à la reprise orale de l'alimentation, à la fréquence des vomissements ou à la nécessité de réinsérer un tube naso-gastrique. La première exonération est survenue au 5.4 jour dans le groupe laparoscopique et au 5,5 jour dans le groupe de chirurgie ouverte sans que la différence ne soit significative. En conclusion: Cette étude infirme l'idée que la chirurgie laparoscopique permet une reprise précoce et bien tolérée de l'alimentation en comparaison à la chirrugie ouverte.

The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer. In April 2006, the Spanish Association of Surgeons started an audited teaching programme. The project was similar to the Norwegian one and several training courses were arranged. Patients were classified into two groups: laparoscopic rectal resection (LR) and open rectal resection (OR). The quality of the mesorectum was scored: complete, nearly complete or incomplete. The circumferential margin (CRM) was considered positive, if tumour was located 1 mm or less from the surface of the specimen. Between 2006 and 2008, 604 patients underwent rectal resection with total mesorectal excision for rectal cancer: 209 patients were included in the LR group and 395 patients in the OR group. There were no differences in terms of number of lymph nodes affected, distance of the tumour from CRM. The mesorectum was complete in 464 (76.8%), nearly complete in 91 (15.1%) and incomplete in 49 patients (8.1%). CRM was negative in 534 patients (88.4%). No differences were observed between the two groups. The overall postoperative morbidity rate was 38.8% in LR group and 44.6% in OR group (P = 0.170). Overall postoperative mortality rate was 2.5%. One patient died (0.5%) in the LR group and 14 patients died (3.5%) in the OR group (P = 0.021). Laparoscopic resection for rectal cancer is feasible with the quality of mesorectal excision and postoperative outcomes similar to those of open surgery.