Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey.

BACKGROUND: This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre. METHOD: A retrospective review of all 7302 patients who underwent stapled haemorrhoidectomy at our department over seven years was conducted. The hospital database was reviewed for subsequent readmissions and re-operations. A questionnaire survey was also sent out to all the patients. RESULTS: A total of 302 patients (4.1%) were admitted with post-operative bleeding and 281 stopped with conservative measures. Twenty one required surgical haemostasis. A total of 301 patients (4.1%) were admitted for an inability to void and 191 (2.6%) had true acute retention of urine, requiring catheterization. There were 124 patients (1.7%) admitted for pain, but all resolved with oral analgesia subsequently. Anal stricture requiring surgery occurred in only 86 patients (1.2%). Serious complications such as staple line dehiscence or anorectal sepsis occurred in seven patients. There were a total of 14 recurrences requiring readmission over this seven-year period, of which 12 were treated successfully with a second haemorrhoidectomy. A total of 1834 patients returned their questionnaire surveys and 95% of the patients reported complete resolution or improvement of their symptoms. Only 27 patients reported subsequent severe bleeding requiring medical attention. CONCLUSION: Stapled haemorrhoidectomy is safe, and most patients are satisfied with the long-term outcome.

Laparoscopic resection for colorectal polyps: a single institution experience.

BACKGROUND: Endoscopic polypectomy, although routinely used for the treatment of colorectal polyps, may be limited by polyp size, location and histology. Laparoscopic resection for malignant polyps and polyps not amenable to endoscopic removal has the advantage of adequate disease clearance as well as the short-term benefits of laparoscopic surgery. This study evaluates the outcomes of such an approach. METHODS: Patients who had laparoscopic resection for colorectal polyps between January 2005 and July 2008 were identified from a prospective database. Polyps that were malignant, large, difficult to snare or incompletely excised, were included. Demographics, perioperative details and histopathology were analysed. RESULTS: Seventy-eight patients (44 male) with a median age of 62.5 years (range 24-86) were studied. The majority (79%) were laparoscopic anterior resections for sigmoid or rectal polyps. Median operating time was 125 min (range, 65-225). Eight cases (10.3%) were converted to open mainly due to adhesions. There was no post-operative mortality. Perioperative complications occurred in seven patients (8.9%). Median hospital stay was 6 days (range 4-78). Median polyp size was 20 mm (range, 5-75). There were 44 benign polyps (55.7%); majority were tubulovillous adenomas (n= 22), and tubular adenomas (n= 10). Thirty-five patients (44.3%) had invasive cancer, with T1 (n= 27) and T2 (n= 2) tumours. Three of these patients (8.6%) had lymph node metastases. Median number of lymph nodes sampled was six (range 0-23). CONCLUSION: Laparoscopic resection is safe and effective for colorectal polyps not amenable to colonoscopic removal, and is especially important for adequate clearance in the case of malignant polyps.

Stapled anastomosis for anterior resection is safe even after previous stapled haemorrhoidectomy--a report of five cases.

INTRODUCTION: Stapled haemorrhoidectomy has become popular for the treatment of symptomatic bleeding or prolapsing piles. There are concerns about the safety of another stapled low colorectal anastomosis after rectal resection if a patient who has had previous stapled haemorrhoidectomy subsequently develops colorectal neoplasia requiring an anterior resection. METHODS: A retrospective review of patients who underwent stapled haemorrhoidectomy and subsequently had anterior resection from 1999 to 2008 was performed. RESULTS: Five patients (all male) were found to have distal sigmoid or rectal tumours on surveillance colonoscopy after stapled haemorrhoidectomy. Median age was 65 years (range 58-71). All underwent anterior resection with stapled end-to-end colorectal anastomosis at median of 29 months (range 18-60 months) after the initial stapled haemorrhoidectomy. Median anastomotic height was 12 cm (range 1-12 cm). A defunctioning ileostomy was created for three out of five patients. All the colorectal anastomoses healed uneventfully. CONCLUSIONS: Stapled colorectal anastomosis may be safely performed after previous stapled haemorrhoidectomy.

Short-term results of DST EEA 33 stapler and neu@ anoscope for stapled haemorrhoidectomy: a prospective study of 1,118 patients from a single centre.

BACKGROUND: Stapled haemorrhoidectomy has been performed with different techniques and staplers. We review our initial experience with the new DST EEA 33 stapler and neu@ anoscope. METHODS: A review of all patients who underwent stapled haemorrhoidectomy using the DST EEA 33 over a 14-month period was conducted. Short-term outcomes of bleeding, pain and retention of urine requiring admission or strictures requiring surgical intervention were studied. RESULTS: There were 1,118 patients operated from August 2007 to October 2008. The median age was 46-year-old (20-82 years) and 51% were females. The median operating time was 15 min (range 5-45 min), and median follow-up was 7 months (range 3-16 months). There were 26 patients (2.3%) who were admitted for inability to pass urine and 20 required catheterisation. Fifty-two patients (4.6%) were admitted for post-operative bleeding. In 32 cases the bleeding stopped spontaneously, while 19 patients required adrenaline injection and packing for hemostasis. Only one patient required surgical hemostasis. Thirty-three patients (2.9%) were admitted for post-operative pain and stayed for a median of 1 day (range 1-4 days). There were 14 patients (1.2%) who developed anorectal strictures requiring surgical intervention. All underwent anoplasty at a median of 3 months post-operatively (range 2-5 months), with good result. There were no recurrent haemorrhoids during follow-up. CONCLUSION: Stapled haemorrhoidectomy using the DST EEA 33 stapler is safe. The neu@ anoscope provides good visibility and handling, and is a useful tool in this procedure.

Laparoscopic versus open right hemicolectomy: a comparison of short-term outcomes.

BACKGROUND: The laparoscopic approach is increasingly becoming the gold standard for colorectal resections. While laparoscopic surgery of the left colon and rectum has been evaluated in many studies, laparoscopic resection of the right colon has not been as widely examined. The aim of this study was to examine the short-term outcomes after laparoscopic right hemicolectomies and to determine if they were superior when compared with those after open resection. PATIENTS AND METHODS: Consecutive cases of laparoscopic right hemicolectomies performed between May 2005 and December 2007, in the Department of Colorectal Surgery, Singapore General Hospital, were compared with a matched series of patients who underwent open surgery. RESULTS: From a total of 37 laparoscopic cases, 36 patients successfully underwent laparoscopic right hemicolectomies. There was one conversion, giving a conversion rate of 2.7%. These 37 patients were compared with 40 patients who underwent open right hemicolectomies. The laparoscopic arm was characterised by shorter length of incisions (5.7 vs. 11.2 cm, p < 0.001) but longer operating times (110.8 vs. 71.6 min, p < 0.001). Mean number of lymph nodes harvested and length of proximal and distal margins were similar in both groups. There were also no significant differences between the groups in terms of narcotic use, recovery of bowel function, length of stay, post-operative morbidity and 30-day mortality. CONCLUSION: Laparoscopic right hemicolectomies are as feasible and safe as the open technique. They confer improved cosmesis with smaller incisions but at the expense of longer operating time.

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction.

INTRODUCTION: Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH. METHODS: From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively. RESULTS: Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure. CONCLUSION: CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.

Phenotypic characteristics of hereditary non-polyposis colorectal cancer by the Amsterdam criteria: an Asian perspective.

BACKGROUND: Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal disease with a 68-82% lifetime risk of colorectal cancer (CRC). This study examined the phenotypic characteristics of CRC in Amsterdam criteria-positive Asian patients from the Singapore Polyposis Registry. METHODS: Hereditary non-polyposis CRC patients, defined by the Amsterdam I and II criteria, prospectively monitored in the Singapore Polyposis Registry over a 16-year period were reviewed. Clinical data were obtained from a computerized database and parameters, such as age of diagnosis, type and location of CRC, other associated cancers in the pedigree, cancer recurrence and survival were analysed. RESULTS: Fifty-two patients (31 men and 21 women) from 42 unrelated families, with a median age of 44.5 years (range 27-73 years), fulfilled either Amsterdam I or II criteria and were included in our analysis. The racial distribution was 91% (n = 47) Chinese and 9% (n = 5) Malays, with a median follow up of 44.9 months (range 2-183 months). Significantly, 69% of tumours in this Amsterdam-defined cohort were left sided, with most being sigmoid cancers. Sixty per cent of all the tumours presented at a late stage (Dukes' C or D). Left-sided tumours presented with more advanced Dukes' stage (P = 0.096) and a higher rate of metastatic disease (P = 0.08) compared with right-sided lesions. There were, however, no significant differences in either disease-free or overall survival between right-sided and left-sided tumours. CONCLUSION: This study emphasized the significant left-sided predominance of CRC in Amsterdam I and II-defined patients from our predominantly Chinese population, in contrast to those classically described in Lynch syndrome. Amsterdam criteria thus may not be suitable for diagnosing HNPCC in Asian populations and a greater emphasis should be made towards routine molecular diagnosis of mismatch repair gene defects in suspected HNPCC patients of Asian decent.

Which is the optimal risk stratification system for surgically treated localized primary GIST? Comparison of three contemporary prognostic criteria in 171 tumors and a proposal for a modified Armed Forces Institute of Pathology risk criteria.

BACKGROUND: This study aims to validate and compare the performance of the National Institute of Health (NIH) criteria, Huang modified NIH criteria, and Armed Forces Institute of Pathology (AFIP) risk criteria for gastrointestinal stromal tumors (GISTs) in a large series of localized primary GISTs surgically treated at a single institution to determine the ideal risk stratification system for GIST. METHODS: The clinicopathological features of 171 consecutive patients who underwent surgical resection for GISTs were retrospectively reviewed. Statistical analyses were performed to compare the prognostic value of the three risk criteria by analyzing the discriminatory ability linear trend, homogeneity, monotonicity of gradients, and Akaike information criteria. RESULTS: The median actuarial recurrence-free survival (RFS) for all 171 patients was 70%. On multivariate analyses, size >10 cm, mitotic count >5/50 high-power field, tumor necrosis, and serosal involvement were independent prognostic factors of RFS. All three risk criteria demonstrated a statistically significant difference in the recurrence rate, median actuarial RFS, actuarial 5-year RFS, and tumor-specific death across the different stages. Comparison of the various risk-stratification systems demonstrated that our proposed modified AFIP criteria had the best independent predictive value of RFS when compared with the other systems. CONCLUSION: The NIH, modified NIH, and AFIP criteria are useful in the prognostication of GIST, and the AFIP risk criteria provided the best prognostication among the three systems for primary localized GIST. However, remarkable prognostic heterogeneity exists in the AFIP high-risk category, and with our proposed modification, this system provides the most accurate prognostic information.

Charity colonoscopy event to commemorate the 185th anniversary of Singapore General Hospital.

INTRODUCTION: Colorectal cancer is now the cancer with the highest incidence in Singapore. However, the overall mortality rate is still about 50% because the majority of the patients present at a late stage of disease. A charity event of screening colonoscopy was offered to the public in conjunction with the 185th anniversary of Singapore General Hospital. The aim of this event was to raise awareness about early detection of colorectal cancer and the safety of colonoscopy. MATERIALS AND METHODS: We conducted a one-off free screening event for colorectal cancer using colonoscopy. Four hundred and ninety individuals responded to a multimedia advertisement for the event. Of these, 220 individuals were selected for the screening based on National Guidelines for colorectal cancer screening and financial status. RESULTS: One hundred and fifty-two individuals turned up for the colonoscopy. The median age was 55 years (range, 22 to 82), with 84 males. Significant pathology was found in 33% of the individuals (n = 51). Colorectal polyps were detected in 34 individuals (22%). A total of 45 polyps were removed, with 20 hyperplastic polyps and 25 adenomas. Eight out of 25 adenomas were located proximal to the splenic flexure. Rectal cancer was diagnosed in 1 individual (0.6%). One individual had a large dysplastic rectosigmoid ulcer and refused further intervention. There were no significant complications from any of the colonoscopies. CONCLUSIONS: Colonoscopy is an invaluable screening modality as it has a high pick-up rate for colorectal polyp and cancer in an asymptomatic population. It is also proven to be safe in our study. It has the added advantage over flexible sigmoidoscopy of detecting a significant number of proximal lesions. Also, therapeutic polypectomy can be performed in the same setting.

Mesenteric desmoid tumors in Singapore familial adenomatous polyposis patients: clinical course and genetic profile in a predominantly Chinese population.

PURPOSE: This study examined the mutational profile of the adenomatous polyposis coli gene in relation to the development of desmoid tumors in familial adenomatous polyposis patients from a predominantly Chinese population. METHODS: This is a retrospective review of all patients with familial adenomatous polyposis coli from the Singapore Polyposis Registry. Identification of specific adenomatous polyposis coli gene mutation was performed and clinical course of associated desmoid disease obtained from case records and a computerized database. RESULTS: Two hundred five patients from 75 families afflicted with familial adenomatous polyposis coli were reviewed, with gene mutations identified in 107 patients. Of these, 23 (11.2 percent) developed desmoids. The male-to-female ratio was 1:1.3 and the ethnic distribution was Chinese (n=17) and Malay (n=6). Of the 92 patients with mutations 5' to codon 1444, 11 patients (12 percent) developed desmoids compared with 6 of 15 (40 percent) patients with adenomatous polyposis coli gene mutations 3' to codon 1444 (P<0.01). The clinical course of desmoid tumors can be divided into stable (n=11), variable (n=3), progressive (n=6), and aggressive growth (n=3). Only 3 (13 percent) patients with aggressive tumor growth required chemotherapy. There was no correlation between the site of mutation and the clinical progression of the desmoids. Seventy-four percent of these desmoids (17/23) developed at a mean interval of 2.98 years after restorative proctocolectomy, while only 30 percent (7/23) were diagnosed preoperatively or discovered during the initial surgery. The most common complications related to the mesenteric desmoids were intestinal obstruction (21.7 percent), ureteric obstruction (17.4 percent), and encasement of superior mesenteric vessels (13 percent). CONCLUSION: The clinical course of desmoids in an individual familial adenomatous polyposis patient remains unpredictable and no reliable genetic marker is available for prognostication in desmoid disease.

Cutaneous and subcutaneous metastases of adenocarcinoma of the colon and rectum.

INTRODUCTION: The interesting topic of cutaneous and subcutaneous metastasis from rectal carcinoma is discussed using 3 cases. CLINICAL PICTURE: The first case was a 70-year-old man with T3N2M0 rectal mucinous adenocarcinoma, who developed an inflammatory subcutaneous metastasis at the left scapula 2 years after anterior resection. The second case was a 51-year-old man with T4N2M0 splenic flexure mucinous adenocarcinoma, who developed metastatic disease including a subcutaneous secondary to the back. The third case was a 53-year-old woman who developed vulval recurrence 10 months after abdomino-perineal resection for a low T3N1M0 rectal adenocarcinoma. TREATMENT: All underwent wide resection. CONCLUSION: This entity is rare and usually signifies disseminated disease if found remote from the resection site and warrants a thorough metastatic work up. A high index of suspicion is recommended when encountered with unresolving skin lesions in cancer patients.

Anal transitional zone cancer after restorative proctocolectomy and ileoanal anastomosis in familial adenomatous polyposis: report of two cases.

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is accepted as the surgical treatment of choice for many patients with familial adenomatous polyposis. The risk of cancer developing in the ileal pouch after this surgery is unknown. Cancer may arise from the ileal pouch after restorative proctocolectomy, but that arising from the anal transitional zone has not been documented in familial adenomatous polyposis. We report two cases of this cancer from the anal transitional zone in patients with familial adenomatous polyposis, with a review of the literature. METHODS: All patients with familial adenomatous polyposis treated with restorative proctocolectomy and ileal pouch-anal anastomosis in The Cleveland Clinic were included in the study. Patients whose surveillance biopsy of the anal transitional zone revealed invasive adenocarcinoma were studied. RESULTS: Among a total of 146 patients with familial adenomatous polyposis who underwent restorative proctocolectomy and ileal pouch-anal anastomosis from 1983 to 2001 in our institution, none developed cancer of the anal transitional zone at up to 18 years of follow-up. However, there were two patients, both of whom underwent surgery elsewhere but who were followed up here, who developed invasive adenocarcinoma of the anal transitional zone. In one of them, cancer was diagnosed three years after a double-stapled ileal pouch-anal anastomosis, whereas in the other, cancer occurred eight years after a straight ileoanal anastomosis with mucosectomy. CONCLUSIONS: Cancer may develop in the anal transitional zone after restorative proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Long-term surveillance of the anal transitional zone needs to be emphasized.

Turnbull-Blowhole colostomy for toxic ulcerative colitis in pregnancy: report of two cases.

PURPOSE: Surgical intervention for toxic ulcerative colitis in pregnancy is associated with a high morbidity and mortality for both mother and her fetus. A limited surgical procedure may be desirable to reduce the risk of maternal and fetal mortality. We describe the use of "blowhole" colostomy and loop ileostomy (Turnbull procedure) in the management of toxic dilation of the colon complicating ulcerative colitis in pregnancy. METHODS: The medical records of two pregnant females with toxic ulcerative colitis were reviewed. The presentations, management, and outcomes of these patients and their neonates are described. RESULTS: The Turnbull-Blowhole colostomy and ileostomy was used in the acute management of toxic ulcerative colitis in two pregnant females. Both mothers and neonates had successful outcomes with resolution of the acute process. Completion proctocolectomy and ileal pouch-anal anastomosis was later performed in both patients. CONCLUSIONS: The colonic decompression and fecal diversion procedure provided minimal operative trauma to the mother and fetus and resulted in successful outcome in the management of toxic ulcerative colitis in pregnancy. We believe the procedure is safe, effective, and relatively simple, which may reduce the morbidity and mortality of toxic colitis in pregnancy.