Colorectal Surgery

Background: The purpose of this study is to represent the change in our concept of principles and techniques of esophagocoloplasty (midcolon esophagocoloplasty) with repetitive performance of the operation and approach of early surgical intervention (within 4-6 month of corrosive ingestion) in place of repetitive trials of dilatations and medical management, provides early better quality of life with lesser period of suffering and saving expenditure of treatment.
Methods: This retrospective study comprises of consecutive 100 patients operated for colon interposition for corrosive stricture of esophagus done at two university linked government teaching hospitals during March 2011 to March 2018. Out of 100 patients, 77 female and 23 male (3:1), mean age 30.6 years (range from 21 to 47 years), mean hospital stay was 14.5 days (range 10 to 25 days) and mean operative duration was 4.5 hours (range 2.5 to 7 hours).
Results: The 30 day in hospital mortality rate was 9%. There were 14 instances of leak at the esophagocolic anastomosis (14%), graft necrosis occurred in 01 patient, 08 patients (8%) developed stenosis at the esophagocolic anastomosis. More than 90% patients (n=77) had ‘Good’ result, 06 patients had ‘Fair’ and 02 had ‘Poor’ result.
Conclusions: Midcolon graft is a solution for confusion in judgment of adequate length of graft and offer uniformity in procedure with effectively lesser operative time. Early (4-6 months after ingestion) operative intervention is advantageous to patients suffering from crippling dysphagia with repeated admission and expenditure from multiple endoscopic dilatations.
Keywords: Corrosive ingestion, Colon interposition, Midcolon esophagocoloplasty, Corrosive stricture

Cost and effectiveness are usually modeled according to one studied event or one health state with parametric or non-parametric methods. In this paper, we propose an original method for assessing total costs while incorporating the dynamics of change in the health status of patients. A semi-Markov model in which the distributions of sojourn times are explicitly defined is developed. The hazard function of sojourn times is modeled by Weibull distributions specific to each transition. A vector of covariates is incorporated into the hazard function of each transition. From a regression model for costs, a cumulative cost function is derived. An estimation of the mean cost per patient in each state defined in the semi-Markov model could thus be made, and this enables us to identify the determinants of direct costs. The results of incremental net benefit (INB) are assessed using the bootstrap method. A cost-effectiveness analysis is performed in order to compare two strategies of follow-up in the colorectal cancer study. Two hundred and forty patients were enrolled in this study. Three health states are defined for patients with curative resection of colorectal cancer: alive without relapse, alive with relapse, and dead. The mean survival is 4.35 and 4.12 years, respectively, in the standard and moderate follow-up groups. We show that mean cost differs significantly by follow-up strategy and Dukes stage. Finally, the INB is assessed and this indicates that neither of the strategies compared was more cost-effective than the other.

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with e...

Background Short-term preoperative radiotherapy and total mesorectal excision have each been shown to improve local control of disease in patients with resectable rectal cancer. We conducted a multicenter, randomized trial to determine whether the addition of preoperative radiotherapy increases the benefit of total mesorectal excision. Methods We randomly assigned 1861 patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of five days) followed by total mesorectal excision (924 patients) or to total mesorectal excision alone (937 patients). The trial was conducted with the use of standardization and qualitycontrol measures to ensure the consistency of the radiotherapy, surgery, and pathological techniques. Results Of the 1861 patients randomly assigned to one of the two treatment groups, 1805 were eligible to participate. The overall rate of survival at two years among the eligible patients was 82.0 percent in the group assigned to both radiotherapy and surgery and 81.8 percent in the group assigned to surgery alone (P=0.84). Among the 1748 patients who underwent a macroscopically complete local resection, the rate of local recurrence at two years was 5.3 percent. The rate of local recurrence at two years was 2.4 percent in the radiotherapy-plus-surgery group and 8.2 percent in the surgery-only group (P<0.001). Conclusions Short-term preoperative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo a standardized total mesorectal excision.

Background: Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus. This randomized clinical trial evaluated the effects of early oral feeding on functional gastrointestinal recovery and quality of life. Methods: One hundred and twenty-eight patients undergoing elective open colorectal or abdominal vascular surgery participated in the trial. Of these, 67 were randomized to a conventional return to diet, and 61 to a regimen allowing resumption of an oral diet as soon as tolerated (free diet group). Results: Reinsertion of a nasogastric tube was necessary in 20 per cent of the free diet group and 10 per cent of the conventional group (P = 0•213). The complication rate was similar for both groups, as was return of gastrointestinal function. A normal diet was tolerated after a median of 2 days in the free diet group compared with 5 days in the conventional group (P < 0•001). Quality of life scores were similar in both groups. Conclusion: Early resumption of oral intake does not diminish the duration of postoperative ileus or lead to a significantly increased rate of nasogastric tube reinsertion. Tolerance of oral diet is not influenced by gastrointestinal functional recovery. As there is no reason to withhold oral intake following open colorectal or abdominal vascular surgery, postoperative management should include early resumption of diet.

Aim Surgical site infection (SSI) remains a common postoperative morbidity, particularly in colorectal resections, and poses a significant financial burden to the healthcare system. The omission of mechanical bowel preparation, as is performed in enhanced recovery after surgery programmes, appears to further increase the incidence. Various wound protection methods have been devised to reduce the incidence of SSIs. However, there are few randomized controlled trials assessing their efficacy. The aim of this study is to investigate whether ALEXIS wound retractors with reinforced O-rings are superior to conventional wound protection methods in preventing SSIs in colorectal resections. Methodology Patients undergoing elective open colorectal resections via a standardized midline laparotomy were prospectively randomized to either ALEXIS or conventional wound protection in a double-blinded manner. A sample size of 30 in each arm was determined to detect a reduction of SSI from 20% to 1% with a power of 80%. Secondary outcomes included postoperative pain. The operative wound was inspected daily by a specialist wound nurse during admission, and again 30 days post-operatively. Statistical analysis was performed using SPSS version 13 with P < 0.05 considered significant. Results Seventy-two patients were recruited into the study but eight were excluded. There were no SSIs in the ALEXIS study arm (n = 34) but six superficial incisional SSIs (20%) were diagnosed in the control arm (P = 0.006). Postoperative pain score analysis did not demonstrate any difference between the two groups (P = 0.664). Conclusion The ALEXIS wound retractor is more effective in preventing SSI in elective colorectal resections compared with conventional methods.

In this clinical study hyperbaric ropivacaine in spinal anaesthesia for lower limb and hip surgery was evaluated and results obtained were compared with those using hyperbaric bupivacaine. Methodology: Two hundred patients scheduled for lower limb and hip surgery were randomly divided into two groups of 100 patients each. These patients received a spinal injection of either 3ml (15mg) of 0.5% hyperbaric ropivacaine or 3ml (15mg) of 0.5% hyperbaric bupivacaine using 25G Quincke type spinal needle. The parameters studied were -onset and total duration of sensory block, onset and total duration of motor block, quality of intraoperative anaesthesia, hemodynamic alterations, and any intraoperative and postoperative complications. Results: The mean onset of sensory block (6±1.3min vs. 3±1.1min; p value<0.05) and motor block (13±1.6min vs. 9±1.3min; p value< 0.05) was significantly slower in ropivacaine group as compared to bupivacaine group. The total duration of sensory block was significantly shorter in ropivacaine group (160±12.9min) than in bupivacaine group (260±16.1min; p value <0.05). The mean duration of motor block was also shorter in ropivacaine group compared to bupivacaine group (126±9.2min vs. 174±12.6min; p value<0.05). Conclusion: The quality of anaesthesia was excellent in both the groups. In conclusion, a solution of ropivacaine (hyperbaric) can be used for spinal anaesthesia and is comparable with hyperbaric bupivacaine in terms of quality of block, but has shorter recovery profile.

Alhamdulillah, syukur ke hadrat Illahi, dengan limpah dan kurnia-Nya dapat saya menghasilkan sebuah buku yang menyediakan maklumat penting mengenai prinsip dan pengenalan stoma, cara penjagaan serta pengurusan stoma dikalangan pesakit. Sekalung penghargaan dan jutaan terima kasih diberikan kepada Universiti Sains Malaysia atas bantuan kewangan melalui Geran Jangka Pendek (304/ PPSP/61312046) yang diberikan dalam penghasilan buku ini.
Secara amnya, stoma dikenali sebagai “mulut” atau “bukaan”. Penggunaan stoma biasanya didapati pada pesakit- pesakit yang menjalani pembedahan terutamanya melibatkan bahagian saluran percernaan iaitu usus kecil dan usus besar.
Sudah pastinya, terdapat seribu satu persoalan yang acapkali diajukan oleh pesakit atau ahli keluarga kepada para petugas perubatan. Antara soalan yang sering diutarakan termasuklah; Apakah itu stoma? Adakah ia menyakitkan? Bagaimanakah cara penjagaan dan pengurusannya? Adakah saya masih boleh menjalani kehidupan seperti biasa?. Bagi para pesakit yang baru sahaja memulakan kehidupan dengan stoma, ia bukanlah suatu perkara yang mudah terutamanya pengendaliannya dalam kehidupan seharian.
Oleh itu, para pegawai perubatan dan jururawat bertugas perlu memberi penerangan secara terperinci kepada pesakit dan ahli keluarga agar mereka memperolehi maklumat yang tepat mengenai stoma. Perkara ini penting bagi memberi kemudahan terutama pesakit disamping mengelakkan berlakunya komplikasi atau kesan buruk pada stoma.
Sejajar dengan itu, buku ini dihasilkan mengandungi maklumat berkaitan prinsip yang digunakan dalam stoma, pendekatan dan pengendalian stoma dalam kehidupan seharian. Di samping itu, buku ini juga menyediakan maklumat tentang pengurusan stoma oleh organisasi bertanggungjawab. Pengalaman pesakit yang pernah dan sedang menjalani kehidupan menggunakan beg stoma turut dikongsikan bersama.
Sebagai pengakhir kata, saya berharap agar buku yang telah dihasilkan ini berupaya menjadi bahan rujukan kepada masyarakat di luar sana terutamanya pesakit dan ahli keluarga yang terlibat dengan stoma. Walaupun penggunaan stoma sedikit sebanyak mengubah rutin harian pesakit, mengetahui ilmu mengenainya amat penting agar kita mampu menjalani kehidupan dengan lebih selamat dan selesa. Selamat Membaca.

The impact of nanotechnology on oncology is revolutionizing cancer diagnosis and therapy and largely improving prognosis. This is mainly due to clinical translation of the most recent findings in cancer research, that is, the application of bio-and nanotechnologies. Cancer genomics and early diagnostics are increasingly playing a key role in developing more precise targeted therapies for most human tumors. In the last decade, accumulation of basic knowledge has resulted in a tremendous breakthrough in this field. Nanooncology, through the discovery of new genetic and epigenetic biomarkers, has facilitated the development of more sensitive biosensors for early cancer detection and cutting-edge multifunctionalized nanoparticles for tumor imaging and targeting. In the near future, nanooncology is expected to enable a very early tumor diagnosis, combined with personalized therapeutic approaches.

Aim: We investigated ENS abnormalities in patients with obstructed defecation (OD), undergoing surgery, together with the presence of estrogen receptors (ER) a, b, progesterone (PR) receptors, and compared the results with those obtained in controls. Method: Full-thickness rectal samples were obtained from 17 patients undergoing STARR for OD associated with rectal intussusception. Samples were analyzed by immunohistochemistry for enteric neurons, enteric glial cells, interstitial cells of Cajal (ICC), For ER and PR, data were compared with those obtained in 10 controls. Results: No differences between patients and controls were found for enteric neurons, whereas OD patients displayed a significant decrease of enteric glial cells in both the submucous (P = 0.0006) and the myenteric (P < 0.0001) plexus. ICC were significantly increased in patients in the submucosal surface (P < 0.0001) and the myenteric area (P < 0.0001). ER receptors were both present on ICC in patients and controls. ER a and PR were absent on enteric neurons and enteric glial cells in patients and controls, whereas ER b were present in all controls and in 69% of patients' enteric neurons (P = 0.18) and in 12% of patients' glial cells (P = 0.0001). Conclusion: Patients with OD associated to rectal intussusception display abnormalities of the ENS and of ER b. Aim: This study evaluated percutaneous endoscopic caecostomy (PEC) placement as an alternative to the Malone surgical approach in the treatment of intractable constipation. Method: Between 2007 and 2010, 18 severely constipated patients underwent endoscopic placement of a Chait TM caecostomy catheter to perform antegrade colonic enemas and they prospectively completed specific questionnaires to assess the frequency of enemas, benefits in terms of constipation (Kess) and their quality of life (GIQLI) after 6 months and yearly. Results: The catheter was successfully introduced in 16 patients (89%). Morbidity included superficial wound infection responsive to antibiotics (n = 1), leaks (n = 6) and local pain (n = 8). After a median follow-up of 25 months, nine patients (56%) still routinely perform ACE (median frequency: 1/day; volume: 1500 ml/enema). One and 2 years after PEC placement, the median Kess score improved respectively from 25 (baseline) to 17 (P < 0.01, n = 15) and 19 (P < 0.05, n = 11). One and 2 years after PEC placement, the median GIQLI score similarly increased from 64 (baseline) to 94 (P < 0.01, n = 15) and 76 (P = 0.2, n = 11) respectively. Conclusion: PEC has a low morbidity rate. After 2 years of follow-up, half of the patients experience significant functional and quality of life improvement, avoiding invasive surgical procedure. LTP3 Sacral nerve stimulation (SNS) certitudes and issues about diagnosis, indications, implant procedures and follow up in bowel dysfunctions: results from the Italian Consensus Expert meeting Aim: This study presents the Italian clinical practice in SNS (44 Coloproctologists with around 1500 implants). Method: During May 2010, 26 physicians completed a questionnaire. A statement was considered as a 'recommendation' if reached 60% of agreement; in July 2010 the physicians met to discuss the dissenting opinions in order to reach consensus. Results: Patient selection: SNS is indicated in idiopathic faecal incontinence (FI) or with sphincter damage (< 180°), not in gas incontinence alone and in severe chronic constipation (slow transit and pelvic floor dyssynergia). Pre-test evaluation: anorectal manometry, transanal US, bowel diary, severity and QoL scales are mandatory in FI; defecography, colonic transit time and colonoscopy in constipation. Change of bowel habits, pelvic floor rehabilitation and drug therapy must precede SNS. Implant procedure: tined lead, two-phase implant procedure, local anaesthesia and antibiotic prophylaxis are recommended. Intraoperative sensory-motor response and radioscopic control are important in lead positioning. Results: During follow up, patient satisfaction and symptoms improvement > 50% (based on bowel diary, severity and QoL scores (which are mandatory to evaluate the efficacy). There is consensus on standard stimulation parameters, but not in cases of unsatisfactory results when reprogramming (also repeated) is recommended. Conclusion: Italian SNS experts are widely agreed on these procedures when they produce homogeneous results; when they do not, opinion is divided. Aim: Faecal incontinence (FI) has a debilitating effect on Quality of Life (QoL). Percutaneous Tibial Nerve Stimulation (PTNS) is being increasingly used to treat FI. This prospective study aimed to evaluate the effect of PTNS on the QoL of patients with FI. Method: Patients with FI completed a validated questionnaire (Faecal Incontinence AQoL) prior to and on completion of 12 sessions of PTNS. The pre-and post-treatment scores for the four domains (lifestyle, coping, depression and embarrassment) were compared for any change using Spearman's test. Results: Ninety-four patients (83F:8M) with a median age of 58 years (range 30–80 years) underwent PTNS. Fifty-two patients (55%) completed the questionnaire prior to treatment and 40 patients (43%) returned the questionnaire after treatment. The median AQol Lifestyle score increased from 2.25 (range 1.0–4.0) to 3.25 (1.1–4.0) following treatment (P < 0.05). The AQol Coping score increased from 1.55 (1.0–3.75) to 2.28 (1.22–4.00) following treatment (P = 0.000005). There were similar improvements in the AQol Depression score, increasing from 2.7 to 3.5 (P = 0.00002) and the AQol Embarrassment Score, increasing from 2.0 to 2.58 (P = 0.001) Conclusion: PTNS improves the quality of life in patients with FI. QoL changes in patients requiring 'top up' sessions need further evaluation.

L'endométriose est une pathologie gynécologique fréquente affectant dix à 15 % de la population féminine. Une endométriose profonde est diagnostiquée chez 20 % des femmes ayant une endométriose. De plus, une endométriose digestive est retrouvée chez cinq à 12 % des patientes porteuses d'une endométriose. L'atteinte colorectale représente 90 % des localisations digestives. Dans le cadre de l'infertilité associée à l'endométriose chez les patientes porteuses d'une atteinte colorectale, nous ne disposons pas de critères prédictifs du succès en termes de taux de grossesse. Dans une revue de la littérature, le taux de grossesse après résection colorectale atteint 63 %. Ces résultats particulièrement élevés posent le problème de la légitimité de la résection colorectale chez les patientes infertiles. Des critères prédictifs de succès sont : un âge jeune ; un score American Society of Reproductive Medicine (ASRM) faible et la réalisation de la résection colorectale par voie coelioscopique. En revanche, la présence d'une adénomyose associée semble être un critère péjoratif. Malgré les résultats encourageants sur la fertilité de la résection colorectale pour endométriose, seules des études comparant les résultats de l'Assistance médicale à la procréation (AMP) à ceux de la chirurgie permettront d'identifier les bonnes candidates à la chirurgie. # 2008 Elsevier Masson SAS. Tous droits réservés.

Background Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high-and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle and nd high-Human Development Index (HDI) countries worldwide. Methods This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. Results 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33–4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76–2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countr...

Background There are no valid and reliable tools to assess competency in advanced laparoscopic surgery at a specialist level. The observational clinical human reliability analysis (OCHRA) may have the required characteristics of such a tool. The aim of this study was to evaluate construct and concurrent validity of OCHRA for competency assessment at a specialist level. Methods Thirty-two video-recorded laparoscopic colorectal resections, performed by experts and delegates of the National Training Program in England, were evaluated. Each video was analysed using OCHRA by identifying errors enacted during surgery. The number of tissue-handling, instrument-misuse, and consequential errors was recorded using video-rating software. Times spent on dissecting (D) and on exposing (E) tissues were also measured (D/E ratio). In addition, two independent expert surgeons globally assessed each video regarding competency (pass vs. fail). Logistic regression was used to predict outcomes. Results A total of 399 errors were identified. There was a significant difference when comparing the expert, pass, and fail groups for total errors (median counts for experts = 4, pass = 10, fail = 17; P \ 0.001). When comparing the pass and fail groups excluding experts, differences could be found for tissue-handling errors (7 vs. 12; P = 0.005), but not for consequential errors (4 vs. 7; P = 0.059) and instrument-handling errors (4 vs. 5; P = 0.320). The D/E ratio was significantly lower for delegates than for experts (0.6 vs. 1.0; P = 0.001). When all four independent variables were used to predict delegates who passed or failed, the area under the receiver operating characteristic curve was 0.867, sensitivity was 71.4%, and specificity was 90.9%. Conclusion OCHRA is a valid tool for assessing competency at a specialist level in advanced laparoscopic surgery. It has the potential to be used for recertification and revalidation of specialists.

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, a...

Background Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high-and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle and nd high-Human Development Index (HDI) countries worldwide. Methods This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. Results 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33–4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76–2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countr...

The purpose of this study was to examine differences in opioid consumption in patients prescribed patient-controlled analgesia (PCA) versus intramuscular injection (IMI) in the early postoperative period after open abdominal surgery. A retrospective audit of 115 patients elicited demographic and clinical data. No significant differences were found between the demographic variables of the PCA and IMI groups. There was a significant difference in the mean opioid dose used during the first 3 postoperative days (p < .01). Mean opioid consumption was 136.89 mg for the PCA group and 50.79 mg for the IMI group. Although there was a reduction in the amount of opioid consumed over the first 3 postoperative days, the PCA group consistently consumed more opioid analgesia compared with the IMI group. Furthermore, there was a disproportionate reduction in opioid consumption between the two groups from Day 1 (r ‫؍‬ .34; p < .01) to Day 3 (r ‫؍‬ .14; p ‫؍‬ .14). This study shows that the amount of analgesia consumed during the postoperative period by patients who had abdominal surgery varied markedly depending on the mode of analgesia (PCA or IMI). The difference in analgesic consumption was also found to increase throughout the 3-day postoperative period. This divergence in the amount of opioid consumption between patients who were prescribed PCA and patients who were prescribed IM analgesia heightens the need for vigilance in assessment and management of pain during the early postoperative period, particularly in patients prescribed IM analgesia on an "as-needed" basis.

Background: Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible. Aims: To ascertain the proportion of primiparas and clinicians who would participate in a hypothetical randomised controlled trial comparing vaginal delivery with elective caesarean section. Methods: Pregnant women (mean 22 weeks gestation) recruited from public and private antenatal clinics at a major tertiary referral centre were interviewed to ascertain their willingness to participate in a hypothetical randomised controlled trial. A selfadministered questionnaire was mailed to midwives, obstetricians, urogynaecologists and colorectal surgeons, and results between groups were compared. Results: One hundred pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 87 colorectal surgeons participated. Only 14% (95% confidence interval (CI), 8-22) of pregnant women and 31% (95% CI, 26-36) of clinicians indicated that they would participate in a randomised controlled trial. Conclusions: A randomised controlled trial comparing vaginal delivery and elective caesarean section may not be feasible due to low levels of willingness to participate, particularly among pregnant women.

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.

The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent fullthickness rectal prolapse; six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, highrisk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.

BACKGROUND: Standardized discharge criteria are considered valuable to reduce the risk of premature discharge and avoid unnecessary hospital stays. The most appropriate criteria to indicate readiness for discharge after colorectal surgery are unknown.

BACKGROUND: Despite improvement in surgical techniques and stapling devices during the last 10 years, colorectal anastomoses are still prone to leakage. Our objective was to evaluate benefit, performance, safety and complications of circular staplers in different rectal and anal anastomosis. Patients and methods: retrospective study 31 cases of rectal and anal anastomosis for different indications using circular staplers of different sizes. Results: 4 cases (12.9%) of intra-operative complication,5 cases of early post-operative complications, 3(9.6%) wound infection one of them with burst abdomen,2cases (6.4%)  of leakage with one of them mortality (3.2%), 2 cases (6.4) of late post-operative stricture. Conclusion: high intra-operative complication with acceptable early and late post-operative complications as these was the early trial of the device but still it is a safe with less operative time and acceptable complications.

Surgeon influenced variables in rectal cancer surgery were assessed. The literature was reviewed to discuss technical and educational issues that may affect the outcome of surgery for rectal cancer. Particular attention was paid to recently debated topics such as adjuvant therapy, colonic J-pouches, total mesorectal excision, and surgeons&amp;#39; training. In some selected cases, transanal techniques with or without neoadjuvant or adjuvant therapy have improved the success of local excision. The biology of rectal cancer has begun to be understood. However, until a more complete understanding with an appreciation of therapeutic implications has been arrived at, surgeon influenced variables will continue to be of paramount importance. Multiple studies have shown tremendous surgeon variability in the outcome after rectal cancer surgery. Some of the variables that have been shown to be important include tumor-free distal and lateral margins, a total mesorectal excision, and an appropriate anastomosis. It has been well demonstrated that proctectomy with straight coloanal anastomosis compromises function as compared with preoperative levels or healthy controls. These deficiencies are further exacerbated by adjuvant therapy. Significant functional improvements, particularly in the first 12 to 24 months after surgery, have been achieved with use of colonic J-pouch. There are many ways by which the surgeon can optimize curative resection for rectal cancer. Appropriate distal and tumor-free lateral margins with total mesorectal excision should be the goals for all tumors in the lower two-thirds of the rectum. Reconstruction should be performed, whenever technically possible, by a colonic J-pouch. Surgeons should be cognizant of their own practice patterns, volume, capabilities, and very importantly results. These results should be audited frequently and willingly shared with patients.

Aim The management of postoperative ileus following colorectal surgery remains controversial. It is the com-monest complication after elective colorectal resection and is associated with an increased incidence of postop-erative adverse events. The prevention and management of postoperative ileus remains unstandardized. This study aims to describe an international profile of gas-trointestinal recovery after colorectal surgery and will assess the role of non-steroidal anti-inflammatory drugs, when used as postoperative analgesia, in expediting the return of gastrointestinal function. Methods A multicentre, student-and trainee-led, prospective cohort study will be conducted across both Europe and Australasia. Adult patients undergoing elec-tive colorectal resection during 2-week data collection periods between January and April 2018 will be included. A site-specific questionnaire will capture compliance to Enhanced Recovery after Surgery components at participating centres. The primary outcome is time to gastrointestinal recovery, measured using a composite outcome of bowel function and oral tolerance. The impact of non-steroidal anti-inflammatory drugs on gas-trointestinal recovery will be evaluated along with safety data with respect to anastomotic leak, acute kidney injury and complications within 30 days of surgery. Discussion This protocol describes the methodology of an international, observational assessment of gastroin-testinal recovery after colorectal surgery. It discusses key challenges and describes how the results will impact on future investigation. The study will be conducted across a large student-and trainee-led collaborative network, with prospective quality assurance and data validation strategies.

Fistula-in ano is an abnormal communication between the anal canal or rectum and perianal skin, which causes a chronic inflammatory response. The most common cause is nearly always by a previous ano-rectal abscess. This study was intended for a clinico-pathological analysis of fistula-in ano and their diagnostic and treatment modalities based on various demographic features and associated conditions. 150 patients were selected who were diagnosed as fistula-in ano admitted and underwent surgical interventions during December 2017 to June 2019. Data related to objectives of the study were collected and analysed. Patients belonging to the age group 31-50 constituted the majority (60%). There was male predominance with ratio of 2.4:1. Half (49.3%) of the cases had DM and 65.3% had perianal abscess before. Most fistula were low anal (80%). MRI Fistulogram was the most sensitive investigation. Fistulectomy was done in three-fourth (n-113, 75.3%). There was no complication in majority and most common complication observed was wound infection (15.3%). In majority (81.3%) of the cases the surgical wound healed by 4 weeks. There was statistically significant difference (p-0.001) in time taken to heal between diabetic and non-diabetic groups. Non-specific inflammation was the histopathology report in 146(97.3%) cases but Tuberculosis was seen in 2 cases.

To evaluate the rate of incisional surgical site infection (SSI) following colorectal cancer surgery in a university hospital and to determine whether duration of prophylactic antibiotic administration can affect the development of this complication. The medical records of 330 patients with colorectal cancer undergoing elective oncological resection between 2003 and 2006 at Siriraj Hospital were reviewed. Patients were divided into two groups according to the duration of antibiotic administration; group A: prophylactic antibiotics were discontinued within 24 hours after surgery and group B: antibiotics administration was extended beyond 24 hours after surgery. Data including rate of incisional SSI were analyzed. There were 180 males and 150 females, with a mean age of 63 years. There were 126 patients (38%) in group A and 204 patients (62%) in group B. There was no statistical difference in patient characteristics and tumor-related variables between the two groups, except tumor loca...

In colorectal surgery, anastomotic leakage (AL) is the most significant complication. Sealants applied around the colon anastomosis may help prevent AL by giving the anastomosis time to heal by mechanically supporting the anastomosis and preventing bacteria leaking into the peritoneal cavity. The aim of this study is to compare commercially available sealants on their efficacy of preventing leakage in a validated mouse model for AL. Six sealants (Evicel, Omnex, VascuSeal, PleuraSeal, BioGlue, and Colle Chirurgicale Cardial) were applied around an anastomosis constructed with five interrupted sutures in mice, and compared with a control group without sealant. Outcome measures were AL, anastomotic bursting pressure, and death. In the control group there was a 40% death rate with a 50% rate of AL. None of the sealants were able to diminish the rate of AL. Furthermore, use of the majority of sealants resulted in failure to thrive, increased rates of ileus, and higher mortality rates. If sealing of a colorectal anastomosis could achieve a reduction of incidence of clinical AL, this would be a promising tool for prevention of leakage in colorectal surgery. In this study, we found no evidence that sealants reduce leakage rates in a mouse model for AL. However, the negative results of this study make us emphasize the need of systemic research, investigating histologic tissue reaction of the bowel to different sealants, the capacity of sealants to form a watertight barrier, their time of degradation, and finally their results in large animal models for AL.

Purpose: Transanal endorectal resection and pull-through technique (TERPT) for Hirschsprung's disease (HD) was described in 1998. It offers the advantages of avoiding laparotomy, laparoscopy, scars, abdominal contamination, and adhesions. The authors compared TERPT with 2 open standard endorectal pull-through approaches.

Colorectal anastomotic leakage is a serious complication of colorectal surgery, leading to high morbidity and mortality rates. In recent decades, many strategies aimed at lowering the incidence of anastomotic leakage have been examined. The focus of this review will be on mechanical aids protecting the colonic anastomosis against leakage. A literature search was performed using MEDLINE, EMBASE, and The Cochrane Collaborative library for all papers related to prevention of anastomotic leakage by placement of a device in the colon. Devices were categorised as decompression devices, intracolonic devices, and biodegradable devices. A decompression device functions by keeping the anal sphincter open, thereby lowering the intraluminal pressure and lowering the pressure on the anastomosis. Intracolonic devices do not prevent the formation of dehiscence. However, they prevent the faecal load from contacting the anastomotic site, thereby preventing leakage of faeces into the peritoneal cavity. Many attempts have been made to find a device that decreases the incidence of AL; however, to date, none of the devices have been widely accepted.

In patients with postradiation rectovaginal fistula who are otherwise healthy and cured of their cancer, repair of the fistula with return to a normal lifestyle is indicated if this repair can be achieved with minimal morbidity, no mortality, and a good prospect for a functionally satisfactory result. The Bricker-Johnston vascular sigmoid colon graft fulfills these conditions by respecting the tissular equilibrium of the radiated rectum and supplying the area with a sound, vascular sigmoid pedicle graft. While this improves tissue vitality locally, it restores rectal function to a near-normal preradiation level and preserves the previously intact sphincter muscles. The concept of this repair is very sound, and its implementation is greatly facilitated technically by the use of mechanical suture instruments. In this presentation, we describe and show the use of stapling instruments in achieving a three-stage repair of a rectovaginal fistula with Bricker and Johnston's technique. [Key words: Radiation injury; Rectovaginal fistula; Bricker-Johnston colon graft; Surgical technique; Gastrointestinal anastomosis] Steichen FM, Barber HKR, Loubeau JM, Iraci JC. Bricker-Johnston sigmoid colon graft for repair of postradiation rectovaginal fistula and stricture performed with mechanical sutures. Dis Colon Rectum 1992;35:599-603.