Combined modality treatment for complex fistulating perianal Crohn's disease.

AIM: Perianal disease affects 33% (range 8-90%) of patients with Crohn's disease. Fistulae are often complex and their management is often difficult and unsatisfactory. This study was a retrospective assessment of a combination of surgical treatment with a standardized protocol of infliximab (IFX) therapy. METHOD: A consecutive series of patients with complex perianal Crohn's disease, presenting between January 2003 and June 2008, were included. Acute sepsis was initially treated with antibiotics and/or surgical drainage (MRI guided when appropriate) and loose seton insertion. IFX was given at 5 mg/kg, at 0, 2 and 6 weeks. End-points were complete, partial or no response. Setons were empirically removed after the second cycle of IFX. RESULTS: Forty-eight patients, average age 46 (range 24-82)years, with perianal Crohn's disease were identified. Three patients stopped IFX after the second infusion, either because of allergy (two patients) or for failure to respond (one patient). Fourteen patients were given maintenance IFX at 8-weekly intervals. Results were recorded for 48 patients, of whom 14 (29%) had a complete response, 20 (42%) had a partial response and 14 (29%) had no response to treatment. Outpatient follow-up was for a median of 20 months. CONCLUSION: Combining surgical procedures with IFX resulted in complete and partial remission in 29% and 42% of patients, respectively. No serious side effects occurred. Using a combined, intensive medico-surgical approach, good initial control of perianal disease was achieved safely.

A proposal for the annotation of recurrent colorectal cancer: the 'Sheffield classification'.

AIM: Current classification systems of large bowel cancer only refer to metastatic disease as M0, M1 or Mx. Recurrent colorectal cancer primarily occurs in the liver, lungs, nodes or peritoneum. The management of each of these sites of recurrence has made significant advances and each is a subspecialty in its own right. The aim of this paper was to devise a classification system which accurately describes the site and extent of metastatic spread. METHOD: An amendment of the current system is proposed in which liver, lung and peritoneal metastases are annotated by 'Liv 0,1', 'Pul 0,1' and 'Per 0,1' in describing the primary presentation. These are then subclassified, taking into account the chronology, size, number and geographical distribution of metastatic disease or logoregional recurrence and its K-Ras status. CONCLUSION: This discussion document proposes a classification system which is logical and simple to use. We plan to validate it prospectively.

Surgery for obstructed defaecation: does the use of the Contour device (Trans-STARR) improve results?

AIM: The objective of the study was to assess safety, efficacy and outcomes of stapled transanal rectal resection (STARR) procedure for obstructed defaecation syndrome (ODS) with two stapling devices, PPH01 and Trans-STARR. METHOD: Data were collected on all patients undergoing PPH01 or Trans-STARR over a 2 year period. Initially, all were treated using the PPH01 device and during the last 8 months using the Trans-STARR. RESULTS: During the analysis period, 25 consecutive patients were treated with PPH01 and 27 patients were treated with Trans-STARR. The median follow up was 12 months (range 3-12 months) for the PPH01 group and 6 months (range 3-12 months) for the Trans-STARR group. Although the resected specimen was larger in the Trans-STARR group (P < 0.001), there was no difference in early adverse events, time to discharge or late complications between the groups. In both groups, postoperative urgency was common (occurring more than occasionally in up to 40% at last review) but the incidence was high preoperatively. ODS and symptom severity scores improved with surgery (P < 0.001). However, the degree of improvement was similar with complete resolution of symptoms occurring in 64% of the PPH01 group and 67% of the Trans-STARR group. CONCLUSION: Our study shows that both procedures are safe and effective in the surgical treatment of obstructed defaecation but despite a larger resection the Trans-STARR procedure does not offer any additional benefit. A policy of individualizing techniques tailored to the extent of prolapse may be appropriate, but requires further evaluation.

Long-term failure and function after restorative proctocolectomy - a multi-centre study of patients from the UK National Ileal Pouch Registry.

OBJECTIVE: There is little information on the long-term failure and function after restorative proctocolectomy (RPC). The results of data submitted to a national registry were analysed. METHOD: The UK National Pouch Registry was established in 2004. By 2006, it comprised data collected from ten centres between 1976 and 2006. The long-term failure and functional outcome were determined. Trends over time were assessed using the gamma statistic or the Kruskal-Wallis statistic wherever appropriate. RESULTS: In all, 2491 patients underwent primary RPC over a median of 54 months (range 1 month to 28.9 years). Of these, 127 (5.1%) underwent abdominal salvage surgery. The incidence of failure (excision or indefinite diversion) was 7.7% following primary and 27.5% following salvage RPC (P < 0.001). The median frequency of defaecation/24 h was five including one at night. Nocturnal seepage occurred in 8% at 1 year, rising to 15.4% at 20 years (P = 0.037). Urgency was experienced by 5.1% of patients at 1 year rising to 9.1% at 15 years (P = 0.022). Stool frequency and the need for antidiarrhoeal medication were greater following salvage RPC. CONCLUSION: In patients retaining anal function after RPC, frequency of defaecation was stable over 20 years. Faecal urgency and minor incontinence worsened with time. Function after salvage RPC was significantly worse.

Direct photographic documentation of ileal mucosa in routine colonoscopy is not an independent valid or reliable proof of completion: quality assurance issues for the national colorectal cancer-screening programme.

INTRODUCTION: The implementation of bowel cancer screening in the UK requires the maintenance of high standards in colonoscopy. Part of this quality control requires the reliable documentation of complete colonoscopy that can be externally audited and assessed. It has been suggested that terminal ileal biopsy is the only definitive and reliable method of confirming caecal intubation, but it is not cost-effective and may now be contraindicated because of potential prion infection. OBJECTIVE: To determine how reliable routine terminal ileal images were as an independent predictor of complete colonoscopy and whether their interpretation was aided with water insufflation or indigo-carmine dye-spraying. Method Forty-nine histologically confirmed terminal ileal images were obtained from a single endoscopist's database; 19 were conventional white-light images, 15 were taken with water insufflation and 15 were taken using chromoscopy enhancement. The images were transferred onto CD-ROM and sent as a questionnaire to 42 colonoscopists who were asked to identify the images as terminal ileum or not. RESULTS: Twenty questionnaires were returned resulting in a total of 980 responses. Overall, the accuracy of positive identification was 53.4%. Water insufflation and chromoscopy improved the accuracy to 68.3% and 63% respectively. Experience of (> 1000 colonoscopies) did not increase overall accuracy. Less experienced endoscopists had an increased accuracy rate with dye-spraying (76.7%vs 59.3%, P < 0.05) but experienced endoscopists had an increased accuracy rate with water insufflation (67.4%vs 63.3%, P > .05). CONCLUSION: Currently, terminal ileal imaging is not a reliable mode of documenting complete colonoscopy. Using water insufflation or dye-spraying coupled with modifications in image acquisition technique may improve its reliability but these methods require further investigation before they can replace the use of caecal landmarks as completion parameters.

Colonic carcinoma presenting as strangulated inguinal hernia: report of two cases and review of the literature.

Inguinal hernia and colonic carcinoma are common surgical conditions, yet carcinoma of the colon occurring within an inguinal hernia sac is rare. Of 25 reported cases, only one was a perforated sigmoid colon carcinoma in an inguinal hernia. We report two cases of sigmoid colon carcinoma, one of which had locally perforated. Each presented within a strangulated inguinal hernia. Oncologically correct surgery in these patients presents a technical challenge.

Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis.

OBJECTIVE: A prospective technical feasibility study of cap assisted ESD for 'curative intent' in patients with residual or local neoplastic recurrence following EMR. Primary end points were second stage R0 resection rate, safety and recurrence. METHOD: Salvage ESD was performed using the Olympus GIF-XQ240 gastroscope and KD-630L insulation tipped knife. Thirty-day mortality, re-admission rates, complications and histological resection status were collected prospectively up to 9 months following index resection. RESULTS: Thirty patients met eligibility criteria. Index R0 resection was achieved in 25/30 (83%) lesions. One patient underwent surgical excision with a second receiving a curative second stage dissection. Ninety-six per cent (29/30) patients were discharged within 24 h of the procedure with a 0% 30-day mortality and re-admission rate. Bleeding occurred in 5/30 (16%) treated successfully with endoluminal haemostasis. There were no perforations. Overall 'cure' rates at short-term follow-up [median 6/12 (range; 3-18)] was 96%. CONCLUSION: This novel application of ESD for first line 'salvage' therapy in treating residual or locally recurrent neoplastic disease may be a safe, minimally invasive and cost effective alternative to direct surgical resection in a select patient cohort.

A selective approach to restorative proctocolectomy without ileostomy: a single centre experience.

OBJECTIVE: A single surgeon series on complications and functional outcomes following restorative proctocolectomy (RPC) is presented. METHOD: An ethically-approved database was used to collect data on all patients undergoing RPC at a single institution. Patient demographics, operative details, complications and functional outcomes were assessed. The impact of ileostomy omission on outcomes was also assessed. RESULTS: Two hundred patients undergoing RPC between 1987 and 2006 were included. There were 122 (61.0%) males and the mean age at surgery was 37.6 years. A J pouch was constructed in 199 (99.5%) patients and an ileostomy omitted in 160 (80.0%). Since adopting a selective policy after the 36th consecutive patient in the series, only 9 (5.5%) patients have had an ileostomy constructed at the time of pouch construction. Complications occurred in 112 (56.3%) patients, with anastomotic stricture (20.6%) and pouchitis (28.6%) being the most common. Anastomotic stricture was more common in those patients receiving an ileostomy (43.6%vs 15.0%, P < 0.001), as were pouch-cutaneous fistulae (5.1%vs 0.6%, P = 0.039) and pelvic sepsis (15.4%vs 5.0%, P = 0.023). Functional outcomes were good, with median 24-h stool frequency of five motions at 1 year. There was increased urgency to defaecate which in part may be due to a significant decline in the use of antidiarrhoeal medication during follow up. CONCLUSIONS: Selective omission of a covering ileostomy in most cases can produce good results following RPC with no increase in the risk of septic complications or pouch failure, and a decreased risk of anastomotic stricture, with maintenance of good function in the majority.

Novel colorectal endoscopic in vivo imaging and resection practice: a short practice guide for interventional endoscopists.

Colorectal cancer remains a leading cause of cancer death in the UK. With the advent of screening programmes and developing techniques designed to treat and stage colorectal neoplasia, there is increasing pressure on the colonoscopist to keep up to date with the latest practices in this area. This review looks at the basic principles behind endoscopic mucosal resection and forward to the potential endoscopic tools, including high-magnification chromoscopic colonoscopy, high-frequency miniprobe ultrasound and confocal laser scanning endomicroscopic colonoscopy, that may soon become part of routine colorectal cancer management.

Endoscopic ultrasound miniprobe staging of colorectal cancer: can management be modified?

BACKGROUND AND STUDY AIMS: Miniprobe ultrasound technology allows in-vivo luminal staging of colorectal cancer with a probe that passes directly through the colonoscope's instrument port. Conventional rigid radial echoscopes are limited by the need for a second examination, an inability to image stenotic lesions, and the inaccessibility of proximal tumours. Since minimally invasive resection techniques are now possible, a sensitive preoperative staging tool is needed to optimize patient selection. The aim of this study was to examine the accuracy of miniprobe ultrasound imaging in the preoperative staging of colorectal cancer and to examine the value of the technique for management decisions. PATIENTS AND METHODS: In a prospective study, a total of 131 consecutive patients with adenocarcinoma or broad-based polyps of the colorectum underwent 12.5-MHz miniprobe ultrasonography examinations conducted by a single endoscopist. Staging criteria for depth of tumour infiltration and nodal status were determined. Nodal disease was defined as the presence of a hypoechoic, round, defined boundary lesion larger than 10 mm in diameter. T0-T1N0 lesions were resected using endoscopic mucosal resection, and patients with lesions staged as T2N1 were referred for surgical resection. Tumour staging using endoscopic ultrasonography was then compared with the histopathological specimens. RESULTS: The accuracy of T staging using endoscopic ultrasonography was 96 % in comparison with the histopathological specimen. Five lesions (4 %) were incorrectly overstaged as T3 - pathology stage T2. Understaging occurred in three lesions (endoscopic ultrasound stage T3 - pathology stage T4). The overall accuracy of nodal staging using endoscopic ultrasonography was 87 % (sensitivity 0.95, specificity 0.71, positive predictive value 0.87, negative predictive value 0.88). CONCLUSIONS: Miniprobe ultrasonography has a high overall accuracy for both T staging and N staging of colorectal cancer and may have an important role in selecting patients suitable for minimally invasive resection techniques.

High magnification chromoscopic colonoscopy or high frequency 20 MHz mini probe endoscopic ultrasound staging for early colorectal neoplasia: a comparative prospective analysis.

BACKGROUND: Successful endoscopic management of early colorectal cancer using endoscopic mucosal resection requires the mandatory prediction of invasive depth and lymph node metastasis. Previous data using the Nagata crypt types Vn(B)/(C) as clinical indicators of T2/N+ disease have shown low specificity (50%) with a tendency to over stage lesions. New mini probe ultrasound "through the scope" imaging permits staging of lesions proximal to the rectum using direct endoscopic visualisation. AIM: To compare the staging accuracy of the Nagata crypt type V with mini probe high frequency 20 MHz endoscopic ultrasound. METHODS: Sixty two patients with a Paris type II flat cancer were imaged using magnification colonoscopy followed by 20/12.5 MHz ultrasound in a "back to back" design. Crystal violet staining (0.05%) at 100x magnification permitted Nagata crypt criteria to be defined. Submucosal deep invasion (sm3+) was defined at ultrasound by the presence or absence of a disrupted third sonographic layer. Predicted T0/1:N0 lesions were resected using endoscopic mucosal resection with the remaining referred for surgery. Ultrasound and magnification staging were then compared with the resected histopathological specimens. RESULTS: One patient was excluded from the study due to poor bowel preparation. Fifty two lesions from 52 patients therefore met inclusion criteria (12 sm1/13 sm2/27 sm3+). Ultrasound (20 MHz) was significantly more accurate for invasive depth staging compared with Nagata stage (p<0.0001) (overall accuracy 93% and 59%, respectively). The sensitivity for lymph node metastasis detection using ultrasound and magnification was 80% and 31%, respectively (p<0.001). The negative predictive value of ultrasound for invasive depth was better than that observed using magnification (88%/47%, respectively). The prevalence of nodal disease overall was 19% (10/52), with 80% (8/10) node positive lesions occurring in the sm3+ lesion group. CONCLUSIONS: High frequency 20 MHz ultrasound is superior to magnification alone when differentiating T1/2 disease with a high positive predictive value for sm3 differentiation. Sm3+ invasion was associated with nodal metastasis.

A prospective analysis of extended endoscopic mucosal resection for large rectal villous adenomas: an alternative technique to transanal endoscopic microsurgery.

INTRODUCTION: Endoscopic mucosal resection is a safe resection tool for selected flat, sessile and lateral spreading tumours of the colon. Transanal microsurgical resection of select rectal neoplastic lesions is another accepted modality. Recent data suggests transanal microsurgery may have high complication rates. We conducted a prospective clinicopathological evaluation of an extended endoscopic mucosal resection technique for highly selected lesions of the rectum and assessed outcome data over a maximal 24-month period. PATIENTS AND METHODS: Eighty-three patients with known rectal neoplastic lesions underwent chromoscopic colonoscopy and on-table staging using a high-frequency (12.5 MHz) mini-probe EUS by a single endoscopist. Patients with T2 or node positive disease were referred for surgery. Following extended endoscopic mucosal resection patients were followed-up at 3, 6, 12 and 24 months post 'index' resection with chromoscopic endoscopy and EUS. Procedural complications, recurrence rates and outcome data were collected. RESULTS: Sixty-two patients fulfilled inclusion criteria. Median procedure time was 48 mins (range 32-126). Lateral spreading tumours (median diameter 30 mm; range 18-42 mm) and sessile lesions (median diameter 38 mm; range 25-86 mm) accounted for 19% and 81% of lesions, respectively. Ninety-seven percent of patients undergoing EMR were discharged within 6-h of procedure. Thirty-day re-admission and death rate was 0%. Bleeding complications occurred in 5/62 (8%) of patients with all achieving complete haemostasis using endo clips. None required transfusion. There were no procedural related complications or perforations. Overall 'cure' rate at a median follow-up of 16 months was 98%. CONCLUSIONS: Extended endoscopic mucosal resection for rectal neoplastic lesions can achieve superior results to those of per-anal excision and trans-anal microsurgery with regard to complications and recurrence rates. Extended endoscopic mucosal resection may be an alternative therapeutic modality in selected patients.

Endoscopic morphological anticipation of submucosal invasion in flat and depressed colorectal lesions: clinical implications and subtype analysis of the kudo type V pit pattern using high-magnification-chromoscopic colonoscopy.

OBJECTIVE: Focal submucosal invasive colorectal cancers (submucosa-sm1) can be managed by endoscopic mucosal resection (EMR) as local lymph node metastasis (LNM) are rare. Lesions are usually flat, depressed or mixed. In deeper vertical submucosal invasion (sm2-3) LNM rates exceed 10-15%. EMR within this group can be complicated by perforation, noncurative resection and may leave LNM untreated. It is therefore essential to differentiate accurately focal sm1 disease from submucosal sm2/3 disease. The aim of this study was to evaluate the relationship between the invasive type V pit pattern using high-magnification-chromoscopic-colonoscopy (HMCC) and submucosal invasive depth for flat and depressed colorectal lesions. METHODS: Total colonoscopy was performed by a highly selected single endoscopist using the Olympus C240Z on 850 patients between January 2001 and July 2003. Kudo type V pits were identified using 0.05% crystal violet (CV) applied directly to the lesion using a steel tipped catheter. Type V pits were graded into class V(n)A-C as described by Nagata. Morphology was documented using the Japanese Research Society classification (JRSC). Histological sections, with reference to mucosal invasive characteristics, acquired using EMR or surgical excision were then compared with the pit pattern. RESULTS: Fifty-one lesions showed a type V pit pattern. The kappa coefficient of agreement between pit the type V pit pattern and histologically confirmed submucosal invasion was 0.51 (95% CI). Following resection, 97% of lesions were correctly anticipated to have sm2 + invasion using pit type Vn(B) and Vn(C) as clinical indicators of invasive disease. Specificity was low at 50% with an accuracy of 78%. CONCLUSIONS: The type V pit pattern is useful for the in vivo staging of submucosal invasive depth in flat and depressed colorectal lesions and is as sensitive as conventional 7.5 MHz EUS. There was a tendency to over-stage lesions and hence the technique is limited by its low overall specificity.

Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection.

BACKGROUND: Lateral spreading tumours are superficial spreading neoplasms now increasingly diagnosed using chromoscopic colonoscopy. The clinicopathological features and safety of endoscopic mucosal resection for lateral spreading tumours (G-type "aggregate" and F-type "flat") has yet to be clarified in Western cohorts. METHODS: Eighty two patients underwent magnification chromoscopic colonoscopy using the Olympus CF240Z by a single endoscopist. All patients had received a previous colonoscopy where an endoscopic diagnosis of lateral spreading tumour was made. All lesions were examined initially using indigo carmine chromoscopy to delineate contour followed by crystal violet for magnification crypt pattern analysis. A 20 MHz "mini probe" ultrasound was used if T2 disease was suspected. Following endoscopic mucosal resection, patients were followed up at 3, 6, 12, and 24 months using total colonoscopy. RESULTS: Eighty two lateral spreading tumours were diagnosed in 80 patients (32% (26/82) F-type and 68% (56/82) G-type). G-type lesions were larger than F-type (G-type mean 42 (SD 14) mm v F-type 24 (6.4) mm; p<0.01). F-type lesions were more common in the right colon (F-type 77% (20/26) compared with G-type 39% (22/56); p<0.01) and more often associated with invasive disease (stage T2) (66% (10/15) v 33% (5/15); p<0.001). Fifty eight lesions underwent endoscopic mucosal resection (G-type 64% (37/58)/F-type 36% (21/58)). Local recurrent disease was detected in 17% of patients (10/58), all within six months of the index resection. Piecemeal resection and G-type morphology were significantly associated with recurrent disease (p<0.1). Overall "cure" rates for lateral spreading tumours using endoscopic mucosal resection at two years of follow-up was 96% (56/58). CONCLUSIONS: Endoscopic mucosal resection for lateral spreading tumours, staged as T1, is a safe and effective treatment despite their large size. Endoscopic mucosal resection may be an alternative to surgery in selected patients.

An evaluation of colorectal endoscopic mucosal resection using high-magnification chromoscopic colonoscopy: a prospective study of 1000 colonoscopies.

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection provides an alternative to surgery for resection of sessile and flat colorectal lesions. High-magnification chromoscopic colonoscopy may allow early detection and anticipate histological diagnosis by identifying colonic crypt patterns. The aim of the present study was to assess the efficacy and safety of en-bloc endoscopic mucosal resection with high-magnification chromoendoscopy in the management of sessile and flat colorectal lesions

A randomised controlled trial of transverse skin crease vs. vertical midline incision for right hemicolectomy.

BACKGROUND: A transverse skin crease incision for right hemicolectomy may result in more rapid recovery than traditional vertical midline incision. This hypothesis was tested with a prospective randomised trial. METHODS: Patients from 2 centres undergoing right hemicolectomy were randomised to received a midline or transverse incision. Incision lengths were sufficient to enable unrestricted resection of the right colon. Patients and carers were blinded to the incisions using strategically placed dressings. Analgesia and oral intake were controlled by the patient. Operative details and recovery parameters were compared. RESULTS: A total of 28 patients were randomised. Demographic data and tumour characteristics of the two treatment groups were similar. The transverse incision group had a slightly shorter median wound (10 cm vs. 11 cm, p<0.05). Operative time, analgesia requirements, recovery parameters (time to discharge, 6.5 vs. 6.5 days) and frequency of complications were otherwise comparable. CONCLUSIONS: A transverse skin crease incision for right hemicolectomy results in a slightly smaller wound but no other advantages were demonstrated compared with a traditional vertical midline incision.

Efficacy of high magnification chromoscopic colonoscopy for the diagnosis of neoplasia in flat and depressed lesions of the colorectum: a prospective analysis.

BACKGROUND: High magnification chromoscopic colonoscopy (HMCC) permits the in vivo examination of the colorectal pit pattern, which has a high correlation with stereomicroscopic appearances of resected specimens. This new technology may provide an "optical biopsy" which can be used to aid diagnostic precision and guide therapeutic strategies. Conflicting data exist concerning the accuracy of this technique when discriminating neoplastic from non-neoplastic lesions, particularly when flat and depressed. AIM: To prospectively examine the efficacy of HMCC for the diagnosis of neoplasia in flat and depressed colorectal lesions using standardised morphological, pit pattern, and histopathological criteria. Clinical recommendations for the use of HMCC are made. METHODS: Total colonoscopy was performed on 1850 patients by a single endoscopist from January 2001 to July 2003 using the C240Z magnifying colonoscope. Identified lesions were classed according to the Japanese Research Society guidelines, and pit pattern according to Kudos modified criteria. Pit pattern appearances were then compared with histopathology. RESULTS: A total of 1008 flat lesions were identified. The sensitivity and specificity of HMCC in distinguishing non-neoplastic from neoplastic lesions were 98% and 92%, respectively. However, when using HMCC to differentiate neoplastic/non-invasive from neoplastic/invasive lesions, sensitivity was poor (50%) with a specificity of 98%. Diagnostic accuracy was not influenced by size or morphological classification of lesions. CONCLUSION: HMCC has a high overall accuracy at discriminating neoplastic from non-neoplastic lesions but is not 100% accurate. HMCC is a useful diagnostic tool in vivo but presently is not a replacement for histology. Requirements for further education and training in these techniques need to be addressed.