Clinical value of pouchogram prior to ileostomy closure after ileal pouch anal anastomosis.

BACKGROUND: In patients who undergo restorative proctocoletomy (RPC) a pouchogram is often used to assess the integrity of the ileal pouch-anal anastomosis (IPAA) before closing the covering ileostomy. There are no good data to support this practice. The aim of the study was to investigate whether contrast pouchography was clinically useful after RPC. METHODS: We conducted a retrospective study of patients who had undergone RPC with a covering ileostomy between September 2013 and September 2015. RESULTS: 61 patients were included. 7 (11%) presented with anastomotic leak and 2 (3%) with pelvic collection, detected on cross-sectional imaging for early postoperative symptoms. In the remaining 52 patients, without immediate postoperative complications, pouchography was performed at a median of 14 weeks (range 7-71 weeks) after RPC. Each patient also underwent examination under anaesthesia (EUA) to assess the integrity of the IPAA on the day of the ileostomy closure. One asymptomatic patient (2%) had an anastomotic leak demonstrated on pouchogram which was subsequently confirmed at EUA. Two patients (3%) with a normal pouchogram, 1 symptomatic and 1 asymptomatic, subsequently had an anastomotic leak demonstrated at EUA. CONCLUSIONS: Pouchogram has a low sensitivity in identifying anastomotic leak before ileostomy reversal in patients after RPC and only rarely changes management. In our series it identified the diagnosis of anastomotic leak in only 1 patient and gave false reassurance in two others. Complications are more frequently detected by clinical history and formal EUA before ileostomy closure.

Five year experience of the treatment of squamous cell carcinoma of the anus.

OBJECTIVES: The best treatment of early stage anal squamous cell carcinoma (SCC) is under debated. Wide local excision (WLE) may be considered adequate for stage 1 anal margin cancer. This study demonstrates our experience in treatment of patients with SCC over 5 years. PATIENTS AND METHODS: We conducted a retrospective study of patients who had undergone anal screening or anal cancer surveillance between October 2010 and 2015 in our department. Each patient underwent anal Pap test, HPV test PCR HPV DNA and cytology by Thin Prep. The examinations were performed by Proctostation THD©. Data were collected and analysed. RESULTS: We included 25 patients, 16 male (64%) and 9 female (36%). Twenty-four patients had SCC and 1 patient had adenocarcinoma. Of this cohort: 10 underwent chemoradiotherapy (CRT) because T3-4 N1-2 M0, 13 underwent only surgery because T1/T2 and 2 patients had CRT and surgery because they already have had anal cancer treated in the past with CRT. Seventeen patients (68%) of this cohort, including 5 with micro-invasive SCCs, had regular follow-up without recurrences. Four patients (17%) died from metastatic disease and 4 patients (17%) had recurrent disease. CONCLUSIONS: In this small cohort we demonstrated satisfactory results in treatment of SCCs, underlining the effective role of surgery in early stages of SCC. Screening program and follow up were fundamental to identify early stage and recurrent disease. Also we found the High-resolution video-proctoscopy a valid diagnostic tool.

Coexisting incarcerated femoral and obturator hernia: a case report.

BACKGROUND: Obturator hernia is a rare condition associated with a high morbidity and mortality. It is an uncommon cause of bowel obstruction most commonly described in elderly females with comorbidity. Surgical intervention is often delayed as a result of subtle presenting signs. Coexisting ipsilateral femoral hernia is an even rarer condition represented by non-exhaustive series in the literature. CASE PRESENTATION: We report a case of a healthy 36 years old lady, nulliparous, with abdominal pain and swelling in the right groin. Preoperative CT showed only a right groin hernia, that was found to be femoral at operative intervention. She recovered and was discharged from hospital but represented with further symptoms of obstruction 9 days later. Diagnostic laparoscopy demonstrated a ipsilateral obturator hernia with associated bowel infarct. The bowel was resected and the defect was repaired. DISCUSSION AND CONCLUSIONS: Obturator hernia presents subtly with medial thigh pain and no lump. They are notorious for difficulty to diagnosis. We describe the first case of coexisting ipsilateral femoral and obturator hernias in a young nulliparous woman with bowel obstruction. Appropriate intraoperative exploration should always be considered.