Comparison of equipment management and cleaning protocols for rigid sigmoidoscopy.

BACKGROUND: To provide outcome data relating to cleaning of rigid sigmoidoscopy equipment comparing commonly used techniques, allowing a framework for general guidelines for use in clinical practice. METHODS: A total of 104 rigid sigmoidoscopies were performed in the rooms of two colorectal surgeons using standard techniques. A three-way randomization was performed adopting the following variables: enzymatic washing versus steam sterilization of the light head, disposable versus reusable bellows and use with versus without an air filter. Aerosol from each system was collected on agar plates, and review of colony count numbers was performed. RESULTS: Gross faecal contamination of the rigid sigmoidoscope light head did not occur during any of the procedures. One plate grew a single-gram negative colony; all other contaminated plates showed environmental flora only. Reusable bellows in combination with an air filter showed lower mean colony counts (environmental flora) from the pre-procedure cultures as well as from the bellows' cultures. CONCLUSION: Enteric flora in this study was rarely aerosolized, and the use of an air filter may decrease this likelihood even further. There is no advantage in using disposable insufflation bellows when compared with the reusable type, allowing considerable cost saving. Washing the light head between procedures with enzymatic solution is a safe cheap and effective method of decontamination.

Continuous wound infusion of local anesthetic for the control of pain after elective abdominal colorectal surgery.

PURPOSE: Local anesthetic wound infusion has been investigated in recent years as a potential alternative to standard analgesic regimens after major surgery. This study investigates the efficacy of a continuous wound infusion of ropivacaine in conjunction with best practice postoperative analgesia after midline laparotomy for abdominal colorectal surgery. METHODS: We performed a randomized, participant and outcome assessor-blinded, placebo-controlled trial on patients presenting for major abdominal colorectal surgery at our institution between December 2003 and February 2006. Patients were allocated to receive ropivacaine 0.54 percent or normal saline via a dual catheter Painbuster Soaker (I-Flow Corporation, OH, USA) continuous infusion device into their midline laparotomy wound for 72 hours postoperatively. RESULTS: A total of 310 patients were included in this study. The continuous wound infusion of ropivacaine after abdominal colorectal surgery conveys minimal benefit compared with saline wound infusion. No statistically significant difference could be shown for: pain at rest, morphine usage, length of stay, mobility, nausea, or return of bowel function. There was a small, statistically significant difference in mean pain on movement on Day 1 for the ropivacaine group (adjusted mean difference -0.6 (range, -1.08 to -0.13)). Although this trend continued on Days 2 and 3, the differences between groups were no longer statistically significant. CONCLUSIONS: Management of pain after major abdominal colorectal surgery is best achieved through adopting a multimodal approach to analgesia. Delivery of ropivacaine to midline laparotomy wounds via a Painbuster Soaker device is safe, but we have not demonstrated any significant clinical advantage over current best practice.

Pentax confocal endomicroscope: a novel imaging device for in vivo histology of the upper and lower gastrointestinal tract.

With advances in endoscopic imaging tools, it is becoming increasingly possible to find, assess and treat numerous gastrointestinal (GI) pathologies at the time of endoscopy. This article focuses on the newly developed Pentax confocal endomicroscope that enables in vivo microscopic imaging of the upper and lower GI tract in histological detail at the time of patient examination without the collection of biopsies. The optical imaging technique has the potential to revolutionize clinical workflows in endoscopy through high-resolution fluorescence imaging of cellular and subcellular detail from the surface and subepithelial layers of the GI mucosa. The device incorporates a full screen, high-resolution charge coupled device as well as a confocal microscope. Preliminary data from blinded clinical studies suggests that the use of this device can increase the diagnostic yield for disease detection in conditions such as ulcerative colitis and Barrett's esophagus, where diagnosis using white light endoscopy is problematic. The early detection and diagnosis of GI abnormalities through the collection of 'optical' biopsies or targeted mucosal excisional biopsies has the potential to improve patient outcomes and enable early therapeutic intervention.

A fluorescence confocal endomicroscope for in vivo microscopy of the upper- and the lower-GI tract.

BACKGROUND: This report describes the development and the clinical evaluation of a novel confocal endomicroscope for obtaining fluorescence images of cellular morphology of the mucosae of the upper- and the lower-GI tract in vivo. The work assessed the feasibility of performing in vivo microscopy at endoscopic examination and evaluated fluorescence imaging protocols. METHODS: Images were collected in real time by using two prototype endoscope configurations, featuring slightly different miniaturized fiber-optic confocal microscopes, fitted integrally into the tips of conventional endoscopes. Confocal scanning was performed at 488 nm illumination for excitation of exogenously applied fluorophores (topical acriflavine and intravenous fluorescein). The images were compared with conventional histology of biopsy specimens and the findings of white-light endoscopy. RESULTS: Confocal endomicroscopy enabled imaging of cellular and subcellular structures (i.e., nuclei) of the GI tract. The crypts of the colonic mucosa, the villi of the terminal ileum and duodenum, the gastric pits of the stomach, and the squamous epithelium of the distal esophagus could be clearly visualized. Acriflavine strongly contrasted the cell nuclei of the surface epithelium, including the absorptive epithelial cells and the mucous secreting goblet cells. Fluorescein stained the extracellular matrix of the surface epithelium and also the subepithelial layers of the lamina propria. Images at increasing depth beneath the epithelium showed the mucosal capillary network. The findings correlated with the histology of biopsy specimens. CONCLUSIONS: The development of a fluorescence confocal endomicroscope makes it practical to examine the upper- and the lower-GI mucosa in cellular detail during otherwise routine endoscopic examination. The results represent a major technical advance in the development of this new optical imaging modality for the in vivo examination of GI tissue.

Local recurrence following surgical treatment for carcinoma of the lower rectum.

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).