A one year audit of the Colorectal Unit at Wits Donald Gordon Medical Centre: 2016-2017.

BACKGROUND: Colorectal surgery has developed into an established surgical subspecialty in South Africa, however there is a paucity of data regarding the epidemiology and surgical outcomes of patients with colorectal disease in this country. The objective is to present the findings of a one-year audit of the Wits Donald Gordon Medical Centre (WDGMC) Colorectal Unit with specific reference to indications, surgical procedures and patient outcomes. METHOD: Patient files from December 2016 to November 2017 were included in a retrospective analysis. The Mann-Whitney U test was used to analyse continuous variables and the Chi-squared test was used to compare categorical variables. RESULTS: During the audit period, 1264 patients were admitted to the Colorectal Unit and a further 564 outpatient endoscopic procedures were performed. There were 306 emergency admissions. 139 elective colorectal resections took place, with a 16% major complication rate, a 12% anastomotic leak rate and no deaths. Rectal resections constituted 66% of the operations and 34% were colonic resections. The median length of stay for all patients undergoing resection was 9 days and there was no statistically significant difference in length of stay between open and laparoscopic cases. CONCLUSION: The WDGMC Colorectal Unit manages a high volume of patients presenting with the full spectrum of colorectal disease.

The dynamic continence challenge - a simple test to predict faecal continence prior to colostomy closure.

BACKGROUND: A common problem in clinical practice is predicting whether a patient will be continent after treatment of a severe perineal injury. Several tests have been described. Anal manometry is unreliable; continence can be normal with low pressures, and poor with high or normal pressures. Endo-anal ultrasound only illustrates anatomical sphincter integrity. The saline continence test involves the quite unphysiological instilling of saline into the rectum, and assessing seepage. What is needed in the prediction of continence is a normal stool simulator. METHOD: We propose the use of powdered instant mashed potato reconstituted with water to the consistency of faeces. About 100 - 150 ml is introduced into the rectum using a catheter-tipped syringe. The patient is instructed to walk around for half an hour. On return the underwear is examined for any soiling. If there is no leakage the colostomy may be reversed. RESULTS: Over the past 15 years, 53 patients have undergone this test. In 47 patients there was no leakage, all had their stomas reversed, and none was incontinent during follow-up. CONCLUSION: The dynamic continence challenge is an accurate physiological test that allows clinicians to simulate the effects of colostomy reversal and assess a patient's continence before actually proceeding to the reversal.

The characteristics of large bowel cancer in the low-risk black population of the Witwatersrand.

Sporadic colorectal cancer may follow a different pathogenic pathway in low-risk populations. The black population of the Witwatersrand has been urbanized for a long time, and has a westernized lifestyle, but colorectal cancer is still infrequent. This study aimed to define the characteristics of the disease in this group. All histologically proven large bowel cancers arising in blacks resident in the Witwatersrand in 1991 and 1996 were extracted from the registry records. Mean age was 54.3 years (range 16-90 years); 6% occurred before 30 years and 22% before 40 years. Male:female ratio was 1.32:1. Over three-quarters of the tumours arose in the rectum and sigmoid; there was no evidence of a right-sided preponderance. More than half the cases were advanced at presentation, and nearly one third were mucinous or signet ring on pathological assessment. Associated adenomata were rare (5.2%), suggesting a different pathogenic pathway from the classical adenoma-carcinoma sequence.

Glyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano: a randomized, controlled trial.

PURPOSE: This study was undertaken to compare local application of a glyceryl trinitrate ointment with lateral internal sphincterotomy for the treatment of chronic fissure-in-ano. PATIENTS AND METHODS: A sample of 24 consecutive patients with chronic anal fissure was randomly allocated to treatment with sphincterotomy or local glyceryl trinitrate. Patients were followed-up for a median of 22 months. RESULTS: All 12 patients healed following sphincterotomy; 10 of 12 healed with local glyceryl trinitrate (P = 0.239). There were no recurrences or side-effects in either group. CONCLUSIONS: Local application of glyceryl trinitrate can avoid surgery in more than 80 percent of patients with chronic anal fissure.

Effect of moderate exercise on bowel habit.

Ten healthy volunteers (six men and four women, aged 22-41 years) were studied in a crossover trial. The study was divided into three one week periods. During each period the subjects either ran on a treadmill, cycled on a bicycle ergometer, or rested in a chair for 1 hour every day. The exercise was performed at two thirds predicted maximum heart rate (equivalent to 50% VO2 max). The sequences were rotated; no studies were performed in the perimenstrual period. Transit was measured by the method of measuring the excretion of a single dose of radio-opaque markers; all stools were collected, weighed, and x rayed after the ingestion of radio-opaque markers. Dietary fibre and fluid intake were measured on the fourth day of each test period by 24 hour record. Lifestyle was otherwise unchanged. Transit time was dramatically accelerated by moderate exercise (both jogging and cycling); however, stool weight, defecation frequency, dietary fibre intake, and fluid intake did not change significantly. Whole gut transit changed from 51.2 hours (95% confidence intervals 41.9 to 60.5) at rest to 36.6 hours (31.6 to 39.2) when riding and 34.0 hours (28.8 to 39.2) when jogging. Riding and running both differed significantly from resting (p less than 0.01); the difference between riding and running was not significant.

Is there a relationship between symptoms of the irritable bowel syndrome and objective measurements of large bowel function? A longitudinal study.

Four patients with the irritable bowel syndrome completed 28 day continuous stool collections and concurrent symptom diaries. The diaries revealed that three patients had multiple pains. When the diaries were compared with objective measurements, no relationship could be detected between the occurrence of pain or any other symptom on the one hand and stool weight, stool form or consistency, mean whole gut transit time, or interdefecatory transit on the other. Patients' descriptions of urgency, looseness and frequency of defecation give little guide to intestinal events, at least using currently available techniques.

Glucose and insulin responses to manufactured and whole-food snacks.

To determine whether realistic snacks containing added sugar evoke excessive insulin responses, 10 healthy subjects consumed four different snack meals, similar in fat and total energy content. Two snacks were based on sugary, manufactured products (chocolate-coated candy bar; cola drink with crisps) and two on whole foods (raisins and peanuts; bananas and peanuts). After the processed-food snacks, plasma-glucose levels tended to rise higher and to fall lower than after the whole-food snacks. The area under the plasma insulin curve was 70% greater after the manufactured snacks than after the raisin-peanut snack. The banana-peanut snack evoked an intermediate insulin response. One subject had pathological insulinaemia after both manufactured snacks but normal responses after both whole-food snacks. These findings suggest that foods and drinks containing added fiber-depleted sugars stress and sometimes overwhelm homeostatic mechanisms but also suggest that the insulin response to food is influenced by the physical state of the food.

Obstructive jaundice in the South African black population.

We report the causes of obstructive jaundice in 56 black South African patients. Chronic pancreatitis and malignant biliary obstruction occurred with equal frequency. These two conditions may be difficult to differentiate clinically and radiologically, and only operative pancreatic biopsy may be diagnostic. Choledocholithiasis caused jaundice in only 7.1% of the patients, reflecting the relatively low prevalence of gallstones in this population.

"Rectal dissatisfaction" in the irritable bowel syndrome. A manometric and radiological study.

Conventional radiographic and manometric criteria failed to distinguish 9 irritable bowel syndrome patients with the symptom of rectal dissatisfaction from 6 without it. Manometric values (including sphincter length, resting and squeeze pressures, and the rectoanal inhibitory reflex, as well as rectal compliance and maximum tolerable volume), radiographic indices (anorectal angle and level of pelvic floor at rest and on straining), and tests of anal and rectal sensitivity were all statistically indistinguishable. Conceivably, the symptom results from incomplete rectal emptying; it may also be an early warning of abnormal perineal descent. Only 4 of the 15 patients with irritable bowel syndrome in this study were able to expel a 50-ml balloon from the rectum in the left lateral position.

Esophagitis in a population at risk for esophageal carcinoma.

A previously unreported high incidence of endoscopically identifiable, diffuse, largely nonulcerative esophagitis, is described in a selected population of Southern African blacks at risk of cancer of the esophagus. This is comparable with findings in similar groups in Iran and China. The incidence of dysplasia and "early" cancer is still undefined in South Africa.