Background
Ileocolic anastomoses are commonly performed for right‐sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual ...trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007.
Objectives
To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications.
Search methods
MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR‐COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. s presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology.
Selection criteria
Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults.
Data collection and analysis
Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta‐analysis when there were sufficient data. Sub‐group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed.
Main results
After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.
Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 0.24, 0.95 p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub‐group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 0.10, 0.75 p=0.01). In subgroup analysis of non‐cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re‐operation, mortality, intra‐abdominal abscess, wound infection, length of stay, showed no significant difference.
Authors' conclusions
Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.
Abstract
Aim
Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision‐making remains ...unclear. The aim of this study was to assess the concordance of decision‐making by colorectal surgeons and the role of the DP in this process.
Method
Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de‐identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work‐up.
Results
After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from
κ
= 0.26 to
κ
= 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from
κ
= 0.21 to
κ
= 0.28. Intra‐anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy.
Conclusion
The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra‐anal rectal prolapse was the most influential DP parameter in treatment decision‐making.
Reported prevalence estimates for fecal incontinence among community-dwelling adults vary widely. A systematic review was undertaken to investigate the studied prevalence of fecal incontinence in the ...community and explore the heterogeneity of study designs and sources of bias that may explain variability in estimates.
A predetermined search strategy was used to locate all studies published that reported the prevalence of fecal incontinence in a community-based sample of adults. Data were extracted onto a proforma for sampling frame and method, sample size, response rate, definition of fecal incontinence used, data-collection method, and prevalence rates. Included studies were critically appraised for possible sources of selection bias, information bias, and imprecision.
A total of 16 studies met the inclusion criteria. These could be grouped into definitions of incontinence that included or excluded incontinence of flatus. The estimated prevalence of anal incontinence (including flatus incontinence) varied from 2 to 24 percent, and the estimated prevalence of fecal incontinence (excluding flatus incontinence) varied from 0.4 to 18 percent. Only three studies were found to have a study design that minimized significant sources of bias, and only one of these used a validated instrument for data collection. The prevalence estimate of fecal incontinence from these studies was 11 to 15 percent. No pooling of estimates was undertaken because there was wide variation in study design.
A consensus definition of fecal incontinence is needed that accounts for alterations in quality of life. Further cross-sectional studies are required that minimize bias in their design and use validated self-administered questionnaires.
Background
Despite regular surveillance colonoscopy, the metachronous colorectal cancer risk for mismatch repair (MMR) gene mutation carriers after segmental resection for colon cancer is high and ...total or subtotal colectomy is the preferred option. However, if the index cancer is in the rectum, management decisions are complicated by considerations of impaired bowel function. We aimed to estimate the risk of metachronous colon cancer for MMR gene mutation carriers who underwent a proctectomy for index rectal cancer.
Methods
This retrospective cohort study comprised 79 carriers of germline mutation in a MMR gene (18
MLH1,
55
MSH2,
4
MSH6,
and 2
PMS2
) from the Colon Cancer Family Registry who had had a proctectomy for index rectal cancer. Cumulative risks of metachronous colon cancer were calculated using the Kaplan–Meier method.
Results
During median 9 years (range 1–32 years) of observation since the first diagnosis of rectal cancer, 21 carriers (27 %) were diagnosed with metachronous colon cancer (incidence 24.25, 95 % confidence interval CI 15.81–37.19 per 1,000 person-years). Cumulative risk of metachronous colon cancer was 19 % (95 % CI 9–31 %) at 10 years, 47 (95 % CI 31–68 %) at 20 years, and 69 % (95 % CI 45–89 %) at 30 years after surgical resection. The frequency of surveillance colonoscopy was 1 colonoscopy per 1.16 years (95 % CI 1.01–1.31 years). The AJCC stages of the metachronous cancers, where available, were 72 % stage I, 22 % stage II, and 6 % stage III.
Conclusions
Given the high metachronous colon cancer risk for MMR gene mutation carriers diagnosed with an index rectal cancer, proctocolectomy may need to be considered.
Background: Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and ...to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis.
Methods: A total of 541 consecutive operations involving anastomoses of the colon and rectum that were carried out between 1999 and 2004 at a single colorectal unit were reviewed. Data concerning 35 variables, relating to patient, tumour and surgical factors, were recorded. Outcomes with respect to anastomotic leakage and mortality were recorded. Data were analysed using univariate and multivariate analyses and odds ratios (OR) calculated.
Results: The overall rate of anastomotic leakage was 6.5% (35 of 541). The most frequently carried out operations were right hemicolectomy and anterior resection of the rectum, with leak rates of 2.2 and 7.4%, respectively. Univariate analysis showed that male gender (OR = 3.5), previous abdominal surgery (OR = 2.4), Crohn’s disease (OR = 3.3), rectal cancer ≤12 cm from the anal verge (OR = 5.4) and prolonged operating time (OR = 2.8) were factors significantly associated with anastomotic leakage. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis. The risk of anastomotic leakage increased when two or more risk factors were present (P < 0.01). The overall mortality was 3.7% and was higher in patients with anastomotic leakage (14.3%; P = 0.01).
Conclusions: Male gender, previous abdominal surgery and low rectal cancer are associated with increased anastomotic leakage rates. These have important implications during preoperative patient counselling and decision‐making regarding defunctioning stoma formation.
Background
Adhesions are the leading cause of small bowel obstruction. Gastrografin transit time may allow for the selection of appropriate patients for non‐operative management. Some studies have ...shown when the contrast does not reach the colon after a designated time it indicates complete intestinal obstruction that is unlikely to resolve with conservative treatment. When the contrast does reach the large bowel, it indicates partial obstruction and patients are likely to respond to conservative treatment. Other studies have suggested that the administration of water‐soluble contrast is therapeutic in resolving the obstruction.
Objectives
To determine the reliability of water‐soluble contrast media and serial abdominal radiographs in predicting the success of conservative treatment in patients admitted with adhesive small bowel obstruction.
Furthermore, to determine the efficacy and safety of water‐soluble contrast media in reducing the need for surgical intervention and reducing hospital stay in adhesive small bowel obstruction.
Search methods
The search was conducted using MESH terms: ''Intestinal obstruction'', ''water‐soluble contrast'', "Adhesions" and "Gastrografin". The later combined with the Cochrane Collaboration highly sensitive search strategy for identifying randomised controlled trials and controlled clinical trials.
Selection criteria
1. Prospective studies were included to evaluate the diagnostic potential of water‐soluble contrast in adhesive small bowel obstruction.
2. Randomised clinical trials were selected to evaluate the therapeutic role.
Data collection and analysis
1. Studies that addressed the diagnostic role of water‐soluble contrast were critically appraised and data presented as sensitivities, specificities and positive and negative likelihood ratios. Results were pooled and summary ROC curve was constructed.
2. A meta‐analysis of the data from therapeutic studies was performed using the Mantel ‐Henszel test using both the fixed effect and random effect models.
Main results
The appearance of water‐soluble contrast in the colon on an abdominal X ray within 24 hours of its administration predicts resolution of an adhesive small bowel obstruction with a pooled sensitivity of 0.97, specificity of 0.96. The area under the curve of the summary ROC curve is 0.98. Six randomised studies dealing with the therapeutic role of gastrografin were included in the review, water‐soluble contrast did not reduce the need for surgical intervention (OR 0.81, p = 0.3). Meta‐analysis of four of the included studies showed that water‐soluble contrast did reduce hospital stay compared with placebo (WMD= ‐ 1.83) P<0.001.
Authors' conclusions
Published literature strongly supports the use of water‐soluble contrast as a predictive test for non‐operative resolution of adhesive small bowel obstruction. Although Gastrografin does not cause resolution of small bowel obstruction there is strong evidence that it reduces hospital stay in those not requiring surgery.
Purpose
Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This ...study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise.
Methods
Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion.
Results
The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (
P
< 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35–1).
Conclusions
This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.
Complex anal fistulas: plug or flap? Muhlmann, Mark D.; Hayes, Julian L.; Merrie, Arend E. H. ...
ANZ journal of surgery,
10/2011, Volume:
81, Issue:
10
Journal Article
Peer reviewed
Background: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of ...these methods of repair.
Methods: A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging.
Results: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty‐one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch‐vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty‐eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty‐two FPs (31% of total) were performed with 7 successful repairs (32%, P= 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P= 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%.
Conclusions: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.
Background
. Access to elective general surgery in New Zealand is governed by clinicians’ judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and ...transparency. Our objective was to describe this judgment in terms of previously elicited cues.
Methods
. We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS.
Results
. Agreement between surgeons was poor (ra = 0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R
2
= 0.66).
Discussion
. The level of agreement reflects surgeons’ practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.
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