Technique for a stapled anastomosis following transanal total mesorectal excision for rectal cancer.

AIM: Transanal total mesorectal excision (taTME) is an emerging and exciting new technique in rectal cancer surgery. As with all novel techniques, new challenges arise, requiring small modifications of the technique. Here we present a simple technique that we have devised to facilitate a stapled anastomosis using standard circular staplers following a taTME. METHOD: We describe the technique in a stepwise fashion with picture - and video illustration. Our experience with this anastomosis in a small cohort of patients is reported. RESULTS: No anastomotic leaks occurred in 12 consecutive patients using this technique following taTME. In one patient a small defect was noticed on direct visualisation of the anastomosis intra-operative, and was closed transanally. So far 8/12 patient had their protective ileostomy reversed with satisfactory function. CONCLUSION: We believe that this technique for a transanal, stapled anastomosis after a transanal TME procedure is safe and reproducible. Objective assessment of longterm functional outcome is required and outcomes need to be compared to other stapled techniques and handsewn anastomoses.

Ileostomy closure in an enhanced recovery setting.

AIM: Hospital stays of 5 days or more are not uncommon following ileostomy closure, yet within an enhanced recovery programme (ERP) it is possible for patients to be discharged on the first postoperative day following anterior resection. The aim of this study was to evaluate whether the introduction of an ERP for ileostomy closure reduced hospital stay without affecting morbidity or readmission rates. METHOD: Consecutive patients undergoing elective ileostomy closure from October 2000 to March 2013 were included in this study. The data were collected prospectively into a database. Enhanced recovery was introduced for all elective ileostomy closures in June 2010. Demographic data, length of stay (LOS), readmission, morbidity and mortality were compared between the two groups using the Mann-Whitney U-test and Fisher's exact test. RESULTS: One hundred and forty-five patients underwent elective ileostomy closure during the study period (37 ERP and 108 pre-ERP). There were no differences between the two groups with respect to demographics, American Society of Anesthesiologists grade, prior radiotherapy or chemotherapy, operative time, body mass index, antibiotic use or closure method. Readmission rates (5% vs 6.5%, P = 1.0), morbidity (8% vs 10%, P = 1.0) and mortality (0% vs 0%) were not significantly different. Median (2 vs 4 days, P < 0.0001) and mean (3.4 vs 5.6 days, P = 0.033) LOS were significantly shorter in the ERP group compared with the pre-ERP group. CONCLUSION: An ERP for closure of ileostomy significantly reduces LOS without adverse effects for patients.

Assessing behaviour in children emerging from anaesthesia: can we apply psychiatric diagnostic techniques?

BACKGROUND: No standardized instrument exists for the systematic analysis of emergence behaviour in children after anaesthesia. Our purpose was to evaluate children's behaviour prior to anaesthetic induction and immediately upon emergence to develop an assessment tool using psychiatric terminology and techniques. METHODS: This prospective study evaluated 25 children from 2 to 9 years of age for preanaesthetic psychosocial factors that might affect behaviour. Children's behaviour was observed from admission to the surgical unit through the induction of anaesthesia. All children received a standardized premedication and induction of anaesthesia. The maintenance anaesthetic was randomized to intravenous remifentanil or inhaled isoflurane. All children underwent repair of strabismus. We assessed the behaviour of children for 30 min upon emergence from anaesthesia for symptoms of pain, distress and delirium using an assessment tool we developed guided by the principles of psychiatry as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). RESULTS: Using our assessment tool, 44% of children demonstrated altered behaviour on emergence; 20% demonstrated complex symptoms with characteristics of delirium. Children anaesthetized with isoflurane had significantly higher postanaesthesia behaviour assessment scores than those anaesthetized with remifentanil (P = 0.04). Age was a significant variable; children <62 months were more prone to altered behaviour than those >62 months (P = 0.02). Scores did not correlate with preanaesthetic risk factors including preexisting psychological or social variables or observed preanaesthetic distress. There was no delay in hospital discharge in children assessed as having altered behaviour. CONCLUSIONS: This exploratory study suggests that postanaesthetic behaviour abnormalities with characteristics of distress or delirium can be categorized using known DSM-IV terminology; in our cohort this behaviour was dependent on age and anaesthetic technique.

Unusual perianal tumours masquerading as abscesses.

Tumours of the perianal region and anal canal are uncommon and can present in a variety of ways. Acute anorectal sepsis is a common condition that usually presents as a painful lump close to the anal margin. Tumours in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. We report three patients who presented to our department with symptoms and signs suggestive of perianal abscess but which on further investigation were discovered to be due to unusual perianal tumours. Only one of the tumours was found to be malignant--a primary perianal mucinous adenocarcinoma; the other two were benign, a leiomyoma and an aggressive angiomyxoma. A high index of clinical suspicion is required to the diagnosis of perianal tumours when assessing patients with painful perianal lumps, particularly those with a long history and those of ethnic origin. Every effort should be made to establish a preoperative diagnosis so that correct treatment can be delivered.

Inactivation and injury of pressure-resistant strains of Escherichia coli O157 and Listeria monocytogenes in fruit juices.

AIMS: To investigate methods for inactivating a pressure-resistant strain of Escherichia coli O157 in fruit juices. METHODS AND RESULTS: Cells of a pressure-resistant strain of E. coli O157 (C9490) were exposed to pressures of between, 0.1 and 500 MPa for 5 min in orange, apple or tomato juice. Treatment at 500 MPa achieved an immediate reduction of 5 log units in apple juice (pH 3.5) and tomato juice (pH 4.1), but only about a 1-2 log10 reduction in orange juice (pH 3.8). The greater level of inactivation in tomato juice than in orange juice of lower pH was due to the presence of low levels (0.7%) of salt in the tomato juice. With the type-strain of E. coli (ATCC 11775) and Listeria monocytogenes NCTC 11994, similar levels of inactivation were achieved at pressures 200 MPa lower. Following storage of pressure-treated orange juice at 4 degrees C for 24 h or 25 degrees C for 3 h, the level of inactivation of E. coli O157 strain C9490 increased to 4.4 or > 7 log10 units, respectively. CONCLUSION: Treatment at 500 MPa may be insufficient to achieve a '5D' reduction in counts of pressure-resistant strains of E. coli, but subsequent death during storage substantially increases process lethality. SIGNIFICANCE AND IMPACT OF THE STUDY: Commercially-practicable pressure processes can be used to inactivate even the most pressure-and acid-resistant strains of E. coli O157, provided that processing and subsequent storage conditions are carefully optimized.

Registration of MR and CT images for skull base surgery using point-like anatomical features.

We have developed a registration technique for combining magnetic resonance imaging (MRI) and computed tomography (CT) images of the skull base for use in surgical planning. The technique is based on user identification of point-like landmarks visible in both modalities. The combination of images involves a small amount of expert interaction, is relatively quick and preliminary evaluation indicates that it is accurate to within 1.5 mm. Registered or fused images can be viewed either on an image processing workstation, or fused images can be printed onto conventional film for convenience in clinical use. We present one patient in order to demonstrate the technique's indications and advantages.