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PubMed1995

Rectal bleeding due to nonspecific colitis in premature infants.

Rectal bleeding is not uncommon in newborn infants. Anal fissures are regarded as the most common cause. We report two cases in which the presence of an anal fissure delayed the diagnosis of nonspecific colitis in premature infants. Rectosigmoidoscopic and biopsy findings are discussed with regard to the heterogeneous group of disorders associated with isolated rectal bleeding in young infants. These procedures may be helpful in ruling out necrotizing enterocolitis in premature infants.

Colitis↗
PubMed2003

Multiple hemorrhoidal ligation: a prospective, randomized trial evaluating a new technique.

PURPOSE: A modified anoscope was developed, with lateral apertures at the left lateral, right anterior, and right posterior quadrants, to enable synchronous exposure and ligation of all three internal hemorrhoids. Results were compared with those for conventional multiple ligation. METHODS: Postligation pain, complications, and outcomes were compared between synchronous ligation with the new anoscope (synchronous group) and three-quadrant ligation with a conventional anoscope with similar overall dimensions (conventional group). RESULTS: Twenty-five patients were prospectively randomized to each group. Postligation pain and analgesic requirements were recorded up to 28 days, and postligation complications and outcomes were evaluated for a minimum of 6 months. Narcotic requirements were lower in the synchronous group, but this difference did not achieve statistical significance (P > 0.05, Student's t-test). Secondary hemorrhage occurred in 1 patient (4 percent) in the conventional group but resolved spontaneously. The synchronous group experienced significantly less pain during the ligation procedure and for 2 days afterward (P < 0.01, Wilcoxon's test). External hemorrhoidal thrombosis developed in 4 percent of the synchronous group and 12 percent of conventionally treated patients, all of whom responded to conservative treatment. Repeat ligation was required less often in the synchronous group (16 percent) than with conventional ligation (28 percent). Surgery (completion hemorrhoidectomy for external thrombosis) was necessary in one patient (4 percent) in each group. Anal stenosis developed in one patient in the synchronous group. CONCLUSION: The new anoscope provides improved exposure of all three internal hemorrhoids and permits optimal placement of the rubber bands; this may account for the decreased postligation pain and lower repeat ligation rates. Synchronous hemorrhoidal ligation is a less painful method of multiple hemorrhoidal ligation and may improve outcomes compared with conventional multiple ligation.

Analgesics↗
PubMed2005

Home study course: summer 2005.

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management, or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1-hour Category I credit of the Physician's Recognition Award of the American Medical Association and 1-hour Category I credit of the ASCCP's Program for Continuing Professional Development. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Adult↗
PubMed2004

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients.

OBJECTIVE: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. SUMMARY BACKGROUND DATA: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. METHODS: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. RESULTS: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. CONCLUSIONS: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.

Adult↗
PubMed2004

Efficacy of transanal endoscopic microsurgery in the management of rectal polyps.

BACKGROUND AND AIM: Transanal endoscopic microsurgery (TEM) was a technique developed to allow the excision of adenomas and early-stage cancers from the rectum and distal sigmoid colon. The aim of this project was to prospectively study surgical morbidity, mortality and the local recurrence rate of all patients treated with this technique. METHODS: All patients undergoing TEM were prospectively evaluated. Endpoints to assess the surgical morbidity and mortality were defined before the study commenced. All patients underwent regular follow up to determine treatment efficacy in terms of the local recurrence rate and survival. RESULTS: The study involved 113 patients, with a mean age of 69 years (standard deviation 14 years, range 30-94 years), and a male to female ratio of 1.4:1. The mean polyp area was 20.5 cm(2) (range 1-169 cm(2)) and the mean height above the anal verge was 9.5 cm (range 4-25 cm). Histology of the tumors found 62 adenomas, 20 carcinomas in situ, and 31 adenocarcinomas. There were no unplanned returns to theater or postoperative deaths. Four patients required readmission within 30 days because of bleeding, and nine patients underwent more radical surgical procedures following histological evaluation of the resected specimens. During a mean follow up of 1.5 +/- 0.8 years (maximum 3.2 years), there have been two recurrences of villous adenomas. The actuarial local recurrence rate at 2 years is 2.4% (95% confidence interval 0.8-4.0%). CONCLUSION: TEM was demonstrated to be a safe surgical procedure, and early follow up has shown it to be an efficacious treatment for benign rectal adenomas and early rectal cancers.

Adenocarcinoma↗
PubMed1986

Ultrastructural findings of rectal and skin biopsies in adult GM1-gangliosidosis.

We report the ultrastructural findings in rectal and skin biopsies in four cases with adult GM1-gangliosidosis. The rectal specimens taken under endoscopic control contained submucosal plexuses, which were easily identified on light-microscopic and electron-microscopic examination. In all cases the ganglion cells in submucosal plexus contained characteristic osmiophilic lamellar inclusions, some of which were typical membranous cytoplasmic bodies, were commonly observed in the ganglion cells, Schwann's cells, vascular endothelial cells, and perithelial cells in rectal biopsy, and membrane-bound clear vacuoles were occasionally seen in the cytoplasm of rectal and cutaneous fibroblasts. However, the axons of unmyelinated nerves in both biopsies showed a normal appearance, and there was no significant change in the eccrine glands in skin biopsy. Comparing rectal and skin biopsies, the former was found to be more valuable for morphological diagnosis of this disease, and our ultrastructural examination of rectal biopsy revealed that enteric nerve cells were involved even in adult GM1-gangliosidosis with a benign course and restricted cerebral lesions.

Adult↗
PubMed1982

Incidence of local recurrence after curative operations for cancer of the rectum.

Between January 1, 1969 and December 31, 1979 a total of 248 patients with infiltrative carcinoma of the middle third of the rectum were treated curatively either by sphincter saving anterior resection (176/248) or by abdomino-perineal excision (72/248). The observed incidence of local recurrence was 21% (52/248). Among the tumor specific factors which influence the development of local recurrence the type of growth (insular - circular, exophytic - ulcerous) and the presence of lymph node metastases at the time of the primary operation proved to be statistically significant. Among the surgical factors a sufficient distal margin of safety in anterior resection could be shown to be of major importance. In order to minimize the risk of local recurrence the distal margin of safety should be at least three cm determined in the fresh operative specimen without tension. The type of operation, be it abdomino-perineal excision or anterior resection, has no influence on the incidence of local recurrence as long as a sufficient distal margin of safety is achieved during anterior resection.

Abdomen↗
PubMed1992

The transanal resectoscope: an under-used instrument?

The use of the urological resectoscope in the treatment of rectal tumours has been described in detail. We report the use of the purpose built transanal resectoscope in the treatment of 34 patients. Fourteen patients had villous adenomas and all but one were relieved of symptoms. Of 20 patients with rectal carcinoma, three presented with acute intestinal obstruction and three had rectal stump recurrences. Palliation was excellent in patients with general symptoms, but the results were disappointing for rectal stump recurrences. Transanal resection (TAR) is a novel form of treatment for patients with rectal obstruction. Two patients in this study had their obstruction successfully relieved by transanal resection alone. This allowed formal bowel preparation and full pre-operative assessment. We feel that this technique is under-used and that the results of treatment justify more widespread acceptance of the procedure.

Adenoma↗
PubMed2004

Transanal endoscopic microsurgery: clinical and functional results.

OBJECTIVE: Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of rectal adenomas and also in selected cases of rectal carcinomas. The aim of this study was to assess the results in a consecutive series of patients after introducing the TEM technique. PATIENTS AND METHODS: All 58 patients operated with TEM from January 1996 to January 1999 were evaluated in a retrospective review. Forty-eight patients answered a clinically validated questionnaire a median of 22 months after TEM. Eighty patients who had undergone transanal excision and 12 who had undergone York Mason's procedure served as a reference group with respect to recurrence rates. RESULTS: The complication rate was 5% (immediate) and 14% (long-term). The overall 30-day mortality rate was zero. An impairment of continence was seen in 18 (37%) patients. Of these, all 18 experienced varying degree of incontinence to liquid stool, 14 also to flatus and 5 of them even to solid stool. The recurrence rate was 11% in adenomas and 14% in cancers; T1, 1 (10%) recurrence and T2, 1 (50%) recurrence. There was a correlation between operating time and impairment of continence as well as recurrence rate. CONCLUSION: TEM is a safe procedure, having a low recurrence rate and an acceptable functional outcome.

Adenocarcinoma↗
PubMed2005

Endoscopic transanal resection of rectal tumours using a urological resectoscope--still has a role in selected patients.

INTRODUCTION: Transanal resection of rectal villous adenomas or adenocarcinomas can be carried out using various modalities such as operative excision, fulguration, laser coagulation or cryotherapy. Transanal endoscopic microsurgery is currently not widely available. Transanal resection can provide effective palliation for locally advanced rectal tumours in patients unfit for abdomino-perineal excision of rectum. A urological resectoscope can be safely and repeatedly used to resect advanced primary or locally recurrent rectal tumours by colorectal surgeons with urological expertise. This study reports our experience of treating rectal lesions with endoscopic transanal resection (ETAR) using the urological resectoscope. METHODS: Patients were identified from one surgeons' prospectively collected operating data. Charts were retrieved and reviewed. RESULTS: Over a 13-year period a total of 43 ETAR procedures were carried out in 20 patients (11 males; mean age 74 years; range 54-92 years) using the urological resectoscope. Twelve (60%) patients had a single resection; 8 (40%) patients required more than one resection; the mean number of procedures per patient was 2.2 (range 1-8). The median interval between resections for recurrent disease (excluding planned repeat resections) was 340 days (range 168-2337 days). Histopathology revealed rectal adenoma (with varying degrees of dysplasia) in 11 (55%) patients and adenocarcinoma in 9 (45%). The majority (30; 70%) of resections were carried out in patients with benign disease, with 13 (30%) in patients with rectal adenocarcinoma. Mean operating time per resection was 25 min. Thirteen (30%) resections were carried out under spinal anaesthetic. There was no procedure related mortality. There were no cases of haemorrhage, rectal perforation, 'TUR syndrome' or pelvic sepsis. No patients with benign disease subsequently developed an invasive carcinoma. CONCLUSIONS: Accepting that this technique provides limited histopathological information regarding extent of resection and tumour clearance, our experience demonstrates that ETAR of rectal tumours using the urological resectoscope can provide a minimally invasive, effective and safe means of treating and palliating patients with benign and malignant rectal disease. There remains a place for this technique in selected patients.

Adenocarcinoma↗
PubMed2004

Transanal endoscopic microsurgery: indications and results after 100 cases.

OBJECTIVE: Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and well-selected malignant rectal tumours since June 1998. We present a prospective descriptive study and analyse the currently accepted indications. PATIENTS AND METHODS: Over a 4-year period 100 patients underwent TEM for treatment of rectal tumours located between 4 and 18 cm from the anal verge. RESULTS: TEM was performed in 71 cases for adenomas, 20 potentially curative excisions for pre-operative staged low-grade carcinoma, 3 palliative procedures for advance carcinoma, 5 carcinoids and 1 solitary ulcer. The local complication rate included wound breakdown in 7 patients, three of them requiring ileostomy. Conversion to laparotomy was performed in two patients. Five adenomas recurred and were successfully treated by TEM. Of the cancers, four patients required immediate salvage therapy by means of total mesorectal excision. Three patients underwent palliative TEM procedures combined with radiotherapy. A single cancer recurrence was treated by means of abdomino-perineal resection after radiotherapy. CONCLUSIONS: TEM appears to be an effective method of excising benign tumours and selected T1 carcinomas of the rectum. The superior exposure of tumours higher in the rectum combined with the greater precision of excision make this minimally invasive technique an attractive surgical approach.

Adenoma↗
PubMed2004

Local resection of rectal tumours using the Salvati operating proctoscope--a safe and effective technique.

BACKGROUND: Per-anal excision can be an effective method for treating large rectal adenomas and selected rectal cancers. This procedure is suitable for adenomas that are too large for colonoscopic excision and for early rectal cancers in patients that are unfit for major resection. PATIENTS AND METHODS: We retrospectively reviewed 37 patients (16 male, 21 female) that had a local resection using a Salvati operating proctoscope. Fifteen had rectal cancer and 22 had rectal adenoma and all have been followed-up for a median of 14 months (range 2-65). Most cancers were staged pre-operatively with endorectal ultrasound and 6 cancer patients received adjuvant therapy. RESULTS: There were no intra-operative complications, 6 minor postoperative complications, none requiring re-intervention (1 peri-anal haematoma, 2 postoperative anaemia, 2 chest complications, 1 secondary haemorrhage) and no peri-operative deaths. Lesions were histologically completely excised in 33 (89%). Thirty-four (92%) did not have any recurrence, 2 (5%) adenomas recurred (both successfully treated with further local resection) and 1 (3%) failed to attend for follow-up. Six have since died, all from comorbid conditions. CONCLUSION: Local resection of rectal tumours using the operating proctoscope is a low cost technique with a low complication rate. Outcome of this treatment is good, and similar to other surgical modalities. Local tumour recurrences are uncommon and can be successfully treated with further local treatment.

Aged↗
PubMed2004

Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery.

OBJECTIVES: A recent study showed less bleeding and need of transfusion after total mesorectal excision (TME) compared with conventional rectal cancer surgery. The aim of this study was to evaluate this result in more details. PATIENTS AND METHODS: Comparison of transfusion history in rectal cancer resections in two different multicentre-studies. Two hundred and forty-six patients were operated in the period 1991-93 with a conventional technique and 311 patients were operated with TME-technique in the period 1996-98. Peri-operative data, including blood transfusion from one month before until one month after the operation, was recorded prospectively. RESULTS: The median intra-operative blood loss was 1000 ml, range 50-6000 ml, before, and 550 ml, range 10-6000 ml (P < 0.001) after introduction of TME. The overall peri-operative transfusion rate was reduced from 73% to 43% (P < 0.001). When adjusted for blood loss, age, gender, weight, and type of resection, TME significantly reduced the risk of receiving intra or postoperative blood transfusion by 0.4 (CI: 0.3-0.6). The variability in blood loss among 12 TME-centres was more than 400% and not correlated with transfusion requirements within the centres. CONCLUSION: TME results in a reduced blood loss and a reduction of blood transfusion, but additional factors others than blood loss seems to influence the decision of transfusion.

Aged↗
PubMed2004

Laparoscopic proctocolectomy with restorative ileal-anal pouch.

OBJECTIVE: The aim of the study was to analyse the outcome of restorative proctocolectomy carried out by laparoscopic surgery. METHODS: A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and July 2003 has been used to identify surgical outcomes in 14 consecutive patients who have undergone laparoscopic RPC. RESULTS: Fourteen patients (5 male), median BMI 24 kg/m(2) have undergone restorative laparoscopic proctocolectomy over a two year period: 13 (ulcerative colitis, one with cancer) and 1 (FAP). The median operation time was 260 min; time has not decreased with experience. There were no intra-operative surgical complications or deaths. Patient controlled analgesia continued for a median of 36 h. The median time to diet was 48 h and median hospital stay 7 days; three patients required nasogastric aspiration for delayed gastric emptying. Eighteen regional lymph nodes were retrieved local to the carcinoma. There was one anastomotic leak. All covering stomas were closed by 6 months (12 by eight weeks). All 14 patients are fully continent, able to suppress urgency and have a median pouch frequency of 4/24 h. None admit to having problems with potency, orgasm sensation, ejaculation, micturition. One lady reports dysparunia. All are highly satisfied with functional outcome and cosmesis. CONCLUSION: We are encouraged to continue to offer our patients the option of a laparoscopic resection.

Adult↗
PubMed2005

Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery.

OBJECTIVE: Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM. MATERIAL AND METHODS: Seventy-nine patients were treated by TEM in the period 1994-2001. The median age was 74 years. The indications for TEM were rectal adenoma in 72 patients and rectal cancer in 7 patients. The tumours were located within 18 cm from the dentate line, median 10 cm. There were performed 69 transmural and 10 mucosal excisions. Mean follow up was 24 months (range 1-95 months). Twenty (25%) patients died during the follow up period, two because of metastases and 18 of other causes. RESULTS: Seven patients had complications. Two (2.5%) patients had peroperative perforation in the intra-abdominal part of the rectum treated by laparotomy. Five (6%) patients had postoperative cardiopulmonal or surgical complications. Eight patients with benign pre-operative histopathological examination had cancer. The local recurrence rate (13%) was similar for adenomas and for carcinomas. CONCLUSION: TEM is a safe technique well tolerated also by high-risk patients, and should be the preferred method in patients with benign tumours in the middle and upper part of the rectum, and in selected cases of early rectal cancer. Benign pre-operative histology does not preclude malignancy and some patients may need further treatment for unexpected malignancy.

Adenoma↗
PubMed2005

The role of colonoscopic endoanal ultrasound scanning (EUS) in selecting patients suitable for resection by transanal endoscopic microsurgery (TEM).

OBJECTIVE: This study was performed to assess the accuracy of colonoscopic endoanal ultrasound scanning (EUS) in the selection of patients with rectal neoplasia suitable for local excision by transanal endoscopic microsurgery (TEM). Our policy is to offer TEM to patients with premalignant (T0) lesions or with T1 tumours that have early disease. PATIENTS AND METHODS: Data were collected prospectively on all patients undergoing EUS for the assessment of rectal neoplasia at our institution over a six-year period. A colonoscopic EUS probe was used to determine whether the tumour breached the muscularis propria (the interface between T1 and T2 disease). Subsequently patients underwent surgical resection, including TEM for those with T0/1 disease. The preoperative stage predicted by EUS (uT stage) was compared to the postoperative histopathological stage of the resected specimens (pT stage). RESULTS: One hundred and fifty-six EUS examinations were evaluated. Sixty-two patients went on to have TEM whilst the remaining 94 had another form of surgery. Of the 62 patients undergoing TEM, 3 were overstaged on EUS. No patients were understaged, giving an accuracy of 95%. Of the 94 patients undergoing an alternative procedure, 5 were overstaged on EUS as having T2 tumours when in fact their histology was T1. Accuracy of EUS at predicting more advanced disease fell to 89%, giving an overall accuracy of 92%. CONCLUSIONS: EUS is accurate at predicting T0/1 vs T2 disease in our institution, and we believe that it is a useful modality in assessing patient suitability for local excision.

Adult↗
PubMed2006

Transanal endoscopic microsurgery: a necessary requirement?

INTRODUCTION: There has been a gradual introduction of transanal endoscopic microsurgery (TEM) into UK practice although the uptake remains variable. This study aimed to assess the availability, application and referral pattern of TEM amongst colorectal surgeons. METHODS: A questionnaire was sent to all consultant members of the Association of Coloproctology. This considered their practice, the availability, application and referral pattern for TEM, and their views on application regarding a selection of rectal tumour scenarios. RESULTS: There were 142 replies representing 116 hospitals and 297 colorectal surgeons. The median catchment area was 280,000 (range 70,000-1,000,000). TEM was available in 18% of hospitals and 72% either performed or referred patents for TEM. Of 21 units performing TEM, 15 received referrals. From 305 TEM procedures performed over the previous year, 206 were referred cases. Eighty-five per cent of consultants considered TEM a necessary technique for optimum management of rectal lesions. Although 61% of consultants considered endoanal excision optimal for low benign rectal tumours, 58% said TEM was optimal for midrectal lesions and between 30% and 55% for high rectal lesions depending if the tumour position was anterior or posterior, respectively. One-third of consultants would perform TEM for a low T1 rectal carcinoma although half would proceed to anterior resection. DISCUSSION: TEM is considered to have a significant role in the optimal management of rectal lesions. The presence of the technique in a limited number of hospitals does appear to provide adequate resources although audit should continue to be centralized.

Colorectal Surgery↗