Pre-emptive triple tributary internal iliac vein ligation reduces catastrophic haemorrhage from sacrectomy during pelvic exenterative surgery.

BACKGROUND: The risk of significant haemorrhage in pelvic exenterative surgery requiring sacrectomy has been well described. Patients requiring a sacrectomy above S3 are placed in the prone position, posing an increased challenge to gaining control of haemorrhage when it occurs. We describe a technique of pre-emptive control of the internal iliac vein and its three named tributaries to tame the pelvis prior to sacrectomy. METHODS: A retrospective, descriptive analysis was performed on a cohort of 25 consecutive patients operated on by one of the authors (AA E) between January 2005 and December 2010; all of whom underwent pre-emptive internal iliac vein triple tributary venous ligation, either unilaterally or bilaterally prior to sacrectomy above the level of S3. RESULTS: The cohort of patients was a heterogenous group ranging in age from 20 to 80 (mean 46.2) years, with primary tumours in 19 (76%), and secondary tumours in 6 (24%). Median operating time was 8.5 h (range 2.32-19.67 h). Median blood loss was 5500 mL (range 1600-18000 mL), with associated median transfusion of packed red blood cells of 9 units (range 0-34 units). Average stay in the intensive care unit was 1 day (range 0-10 days), with a median length of hospital stay of 18 days (range 5-148 days). There was no intraoperative mortality, with one death at 30 days secondary to gram-negative septicaemia. Postoperative morbidity occurred in 17 (68%) patients. CONCLUSION: Our results show that pre-emptive triple tributary internal iliac vein ligation is feasible for taming the pelvis prior to sacrectomy in the prone position where control of significant haemorrhage can prove challenging. The technique has broader relevance for visceral resections in the pelvis involving the pelvic side walls.

Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse.

BACKGROUND: The objectives of this study were to compare both subjective clinical outcomes and the objective stress response of laparoscopic and open abdominal rectopexy in patients with full-thickness rectal prolapse. Abdominal rectopexy for patients with rectal prolapse is well suited for a laparoscopic approach as no resection or anastomosis is necessary. METHODS: Forty patients with a full-thickness rectal prolapse were randomized before operation to a laparoscopic group and an open group. They agreed to conform to a clinical pathway (CP) of liquid diet (CP1) and full mobility (CP2) on day 1, solid diet (CP3) on day 2 and discharge (CP4) before day 5. Their compliance was monitored by an assessor blinded to the operative group, who also rated pain and mobility. Patient-controlled morphine use was documented. Neuroendocrine and immune stress response and respiratory function were measured. RESULTS: Some 75 per cent of all clinical pathway objectives of early recovery were achieved in the laparoscopic group compared with 37 per cent in the open group (P < 0.01). Significant differences in favour of laparoscopy were noted with regard to narcotic requirements, and pain and mobility scores. Differences in objective measures of stress response favouring laparoscopy were found for urinary catecholamines, interleukin 6, serum cortisol and C-reactive protein. No differences were noted in respiratory function but significant respiratory morbidity was greater in the open group (P < 0.05). None of the measured outcomes, subjective or objective, favoured the open group apart from operating time, which was significantly shorter (153 versus 102 min; P < 0.01). CONCLUSION: This study has demonstrated significant subjective and objective differences in favour of a laparoscopic technique for abdominal rectopexy. The advantages were all short term but no evidence of any adverse effect on longer-term outcomes was observed.

Is there an association between fecal incontinence and lower urinary dysfunction?

BACKGROUND: Urinary and fecal incontinence in females are both common and distressing conditions. Because common pathophysiologic mechanisms have been described, an association between the two would be expected. The aim of this study was to determine whether patients with lower urinary tract dysfunction have concomitant fecal incontinence when compared with age and gender matched community controls and, second, to determine whether they have predisposing factors that have led to lower urinary tract symptoms and concomitant fecal incontinence. METHODS: A case-control study was performed by means of detailed questionnaire and review of investigation results. One thousand consecutive females presenting for urodynamic investigation of lower urinary tract dysfunction, were compared with 148 age and gender matched community controls. RESULTS: Frequent fecal incontinence was significantly more prevalent among all cases than among community controls (5 vs. 0.72 percent, P = 0.023). Occasional fecal incontinence was also more prevalent (24.6 vs. 8.4 percent, P < 0.001). Fecal incontinence was not significantly more prevalent among females with genuine stress incontinence (5.1 percent) when compared with females with detrusor instability (3.8 percent) or any other urodynamic diagnosis. Symptoms of fecal urgency and fecal urge incontinence were significantly more prevalent among those with a urodynamic diagnosis of detrusor instability or sensory urgency than among females with other urodynamic diagnoses or community controls. Multivariate analysis comparing cases with fecal incontinence with other cases and also with community controls did not indicate that individual obstetric factors contributed significantly to the occurrence of fecal incontinence in these patients. CONCLUSIONS: There is an association between genuine stress incontinence, lower urinary tract dysfunction, and symptoms of fecal incontinence, but the exact mechanism of injury related to childbirth trauma is questioned.

Island flap perineoplasty decreases the incidence of wound breakdown following overlapping anterior sphincter repair.

OBJECTIVE: Overlapping anterior sphincter repair is the accepted treatment for faecal incontinence resulting from sphincter disruption, however, wound breakdown has been reported to occur in up to 30% of patients. The aim of this study was to assess whether the type of wound closure affected the incidence of wound breakdown, and in particular whether island flap perineoplasty decreased this incidence. METHODS: An historical control study was performed evaluating wound outcomes in patients undergoing different methods of wound closure after sphincter repair. Data were obtained from a prospectively collected database. RESULTS: 85 patients who underwent overlapping sphincter repair were studied. Five patients had their wounds left open to heal by granulation. Of the remaining 80 patients, wound dehiscence occurred in 33 patients (41%). When wound breakdown did occur, the mean time to healing was 9.1 weeks. Wound dehiscence was found to occur significantly less frequently in patients having an island flap perineoplasty than in those having other forms of wound closure (15 vs 54%; P=0.0015). The presence of a complex injury such as cloacal defect or recto-vaginal fistula was also found to increase the incidence of wound breakdown, however, performing additional operations at the time of sphincter repair such as levator-plasty, gynaecological procedures or defunctioning colostomy did not affect the incidence of wound disruption. CONCLUSIONS: Wound disruption following overlapping anterior sphincter repair occurs in a significant proportion of patients and results in prolonged healing. Island flap perineoplasty significantly decreases the incidence of wound disruption in comparison to other forms of wound closure.

Rectal cancer: changing patterns of referral for radiation therapy 1982-1997.

BACKGROUND: The purpose of the present study was to evaluate the changing role of radiation therapy in rectal cancer and to determine the patterns of referral of patients during a 15-year period. METHODS: From 1982 to 1997, 464 patients with carcinoma of the rectum were referred to the Department of Radiation Oncology, Royal Prince Alfred Hospital: 79% of patients had locoregional disease alone and 21% had distant metastasis. Radiation therapy consisted of irradiation (definitive or palliative) alone to the primary tumour in 9.7% of cases; preoperative radiation in 7.3% of cases: preoperative chemoradiation in 7.5% of patients: postoperative radiation in 15.3% of patients: postoperative chemoradiation in 12.31% of patients: treatment of pelvic recurrence in 23.5% of patients and treatment of metastases in 9.1% of patients. The remainder were treated elsewhere (1.9%) or not treated (13.4%). RESULTS: There was an average annual 14% increase in referrals over the accrual period. Recurrent rectal cancer decreased from approximately 30% of referrals during 1982-91 to approximately 10% in 1995-7. The use of postoperative adjuvant radiation reached a peak of 50% in 1993. The use of preoperative radiation increased suddenly in 1994 from < 10% to a sustained rate of approximately 30% of referrals. The use of chemoradiation commenced in 1990 for postoperative adjuvant treatment and in 1994 for preoperative treatment. The median survival time from initial diagnosis was 35 months, with 2- and 5-year survival rates of 62 and 28%, respectively. Survivals at 5 years for patients treated with preoperative and postoperative radiation (with or without chemotherapy) and with recurrent disease were 56, 44 and 21%, respectively. CONCLUSIONS: The present study illustrates the changing role of radiation therapy in the management of rectal cancer. The increase in referrals over the observation period was due to increased multidisciplinary input into the initial management of these patients, based on reported clinical trials. The steady increase in the use of adjuvant therapy has paralleled a decrease in referrals for treatment of recurrence and reflects current clinical results. The sequencing of adjuvant therapy is changing currently, with greater emphasis on preoperative adjuvant treatment. Currently most adjuvant therapy includes chemotherapy.

Biofeedback for fecal incontinence using transanal ultrasonography: novel approach.

PURPOSE: Neosphincter procedures may prove to be the treatment of choice for patients with neuropathic fecal incontinence but are rarely proposed for milder forms of the disease. Biofeedback may prove beneficial to these patients but is yet unproven. The objectives of this study were to develop a method of performing biofeedback using transanal ultrasound to teach the patient to contract repetitively and to determine biologic measures of sphincter function using transanal ultrasound in healthy and incontinent patients. METHODS: Initial uncontrolled studies were performed to determine the compliance, normal values, biologic measures of external sphincter strength (isotonic and isometric fatigue times), and early efficacy data using continence scores and visual analog scale scores. RESULTS: Forty-four patients were assessed during three months, with relative improvements in continence scores (St. Mark's Hospital, 40 percent; Pescatori, 20 percent) and patient and investigator visual analog scale scores (38 percent for both) and measurable increase in biologic fatigue times measured by transanal ultrasound. CONCLUSIONS: Transanal ultrasound seems to be a method of teaching external sphincter contraction and measuring sphincter strength with good initial compliance. Clinically and statistically significant improvements in incontinence scores, visual analog scale scores, and biologic strength of the external sphincter were detected in the short-term follow-up with uncontrolled data. The randomized, controlled trial that we have begun will either confirm or refute these results.

Evolution of the pelvic pouch procedure at one institution: the first 100 cases.

BACKGROUND: Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series. METHODS: Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation. RESULTS: After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis. CONCLUSIONS: Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.

Abdominal surgery in the older Crohn's population.

BACKGROUND: The surgical literature perceives that the elderly cohort of Crohn's patients may have increased risk with surgery. METHODS: A retrospective review and prospective database analysis of all patients with histologically proven Crohn' s disease who had a laparotomy at a single Sydney teaching hospital were performed. The last laparotomy of each patient was included in the analysis for morbidity and mortality to assess whether an older cohort was at an increased risk. RESULTS: A total of 156 patients had 298 laparotomies for histopathologically proven Crohn's disease. The frequency distribution of age at last laparotomy was bimodal, and the statistically determined cut-off age between younger and older cohorts was 55 years. Thirty-three patients were older than 55 years. There was no difference in duration of symptoms before first diagnosis (older, 17 months vs younger, 25 months), previous number of Crohn's operations (42.4 vs 39.8%), or duration of known Crohn's disease. Isolated large bowel disease was more common in the elderly cohort (42.4 vs 18.7%, chi2 = 8.09, P < 0.01). Small bowel and ileocaecal resections were more common in the younger cohort (72.4 vs 51.6%, chi2 = 5.19, P < 0.025). There was one death in each cohort (overall mortality 1.3%) and anastomotic leak rates (defined as the number of leaks per number of patients with anastomoses), were 4.3% (older) vs 5.3% (younger) despite frank sepsis present in 21.2% of all subjects at the time of surgery. The older group had more cardiac (18.2 vs 0.8%, P < 0.001) and respiratory complications (18.2 vs 2.4%; P = 0.0003) and a longer mean but not median postoperative hospital admission. CONCLUSIONS: In conclusion, clinical features and presentation are similar in the older and younger Crohn's patients having a laparotomy. However, in the older patient there is a greater likelihood of large bowel disease, ileocaecal resection is done less commonly, there is a higher risk of minor cardiopulmonary postoperative complications, but with similar mortality and anastomotic leak rates to the younger patient.

Defunctioning of the anorectum: historical controlled study of laparoscopic vs. open procedures.

BACKGROUND: Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy. OBJECTIVES: The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group. METHODS: Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented. RESULTS: Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7 vs. 89.9 mg; P < 0.01), an earlier tolerance of both liquid (mean, 2.1 vs. 3.7 days; P < 0.01) and solid diets (mean, 3.6 vs. 5.5 days; P < 0.001), and an earlier time to passage of both flatus (mean, 2.2 vs. 3.6 days; P < 0.001) and feces (mean, 3.7 vs. 5.6 days; P < 0.001). Operating time was longer for the laparoscopic group (mean, 176 vs. 104 minutes; P < 0.001), whereas median time to discharge from hospital was shorter (median, 8 vs. 11 days; P = 0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients. CONCLUSIONS: In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.

Successful overlapping anal sphincter repair: relationship to patient age, neuropathy, and colostomy formation.

BACKGROUND: Fecal incontinence from single anal sphincter defects are surgically remedial and commonly the result of obstetric injuries. Overlapping anal sphincter repair has previously been associated in small series with good results in 69 to 97 percent of patients. OBJECTIVES: The aims of this study were to assess the results of overlapping anal sphincter repair in one institution and to assess the effects of age, presence of a neuropathy, and addition of a temporary colostomy on the success of surgery. METHODS: A study of 57 overlapping anal sphincter repairs in 56 (54 females) patients at the Royal Prince Alfred Hospital during a six-year period was performed. All patients were investigated preoperatively with endoanal ultrasound and concentric needle electromyography. Patients have been assessed prospectively since 1994 with a questionnaire, including a four-point Likert scale of continence level, the St. Mark's incontinence scoring system (range, 0-13), the Pescatori incontinence scoring system (range, 0-6), and patient assessment of success or failure of the overlapping anal sphincter repair. A colostomy was selectively formed in conjunction with an overlapping anal sphincter repair in 21 patients (8 preoperatively, 13 simultaneously), and 18 patients had a concomitant neuropathy (3 unilateral, 15 bilateral). RESULTS: After a median follow-up of 18 months, median continence scores overall had improved from St. Mark's incontinence scoring 13 to 3 (P < 0.0001) and Pescatori incontinence scoring 6 to 2 (P < 0.0001). Forty-nine of 57 (86 percent) repairs have been successful, and 8 are considered to be failures. Twenty-one of 27 (78 percent) repairs in patients younger than 40 years of age were successful, as were 28 of 30 (93 percent) repairs in patients older than 40 years of age (P = 0.10). Four of 18 (22 percent) repairs associated with a neuropathy failed compared with 4 of 39 (10 percent) without a neuropathy (P = 0.21). Improved or normal continence was achieved in 17 of 21 (81 percent) patients with a stoma and overlapping anal sphincter repair and in 32 of 36 (89 percent) patients with an overlapping anal sphincter repair alone (P = 0.32). The presence of a stoma did not improve the rate of wound healing by primary intention (62 percent for stoma vs. 64 percent for overlapping anal sphincter repair alone; P = 0.55). CONCLUSIONS: Single anal sphincter defects can be successfully treated with an overlapping anal sphincter repair. There is no improvement in primary healing with selective stoma formation. Age of the patient and presence of a neuropathy should not detract from proceeding with overlapping anal sphincter repair when singular anal sphincter defects are detected on endoanal ultrasound in muscle that is still active.

Are special investigations of value in the management of patients with fecal incontinence?

PURPOSE: The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone. METHODS: Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography. RESULTS: In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy. CONCLUSIONS: Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.

Laparoscopic rectopexy using mesh fixation with a spiked chromium staple.

UNLABELLED: Abdominal rectopexy for patients with rectal prolapse is well suited for performance laparoscopically because no resection or anastomosis is necessary, with potential benefits being a decrease in postoperative pain, better cosmesis, and an earlier return to normal activity. PURPOSE: Objectives of this study were to determine the feasibility of laparoscopic abdominal rectopexy using a solitary spiked chromium staple to fix the mesh to the sacrum and to compare initial results with consecutive previous abdominal rectopexies (historical control study). METHODS: Duration of operation (anesthetic plus surgery), the day a solid diet was first tolerated, day of discharge, and patient morphine requirements in the first 48 hours were documented prospectively for the laparoscopic group and retrospectively from medical records for an open abdominal rectopexy group. RESULTS: Laparoscopic rectopexy group had lower morphine requirements when using patient-controlled analgesia (mean, 38.2 vs. 100.6 mg; P < 0.02), an earlier tolerance of solid diet (mean, 2.7 vs. 5.8 days; P < 0.001), and an earlier discharge from the hospital (mean, 6.3 vs. 11.0 days; P < 0.01). Operating time was longer for the laparoscopic group (mean, 198 vs. 130 minutes; P < 0.001). CONCLUSIONS: Laparoscopic rectopexy is feasible, may have benefits in reducing postoperative pain, and may aid earlier return to normal diet and activity. Given the inherent bias of a historical control study, a randomized controlled study has commenced to confirm these results.

Gracilis myocutaneous flap to reconstruct large perineal defects.

Large perineal defects can occur after surgery for recurrent malignancy particularly after adjuvant radiotherapy or in complex chronic perineal inflammatory conditions. Quality of life can be severely impaired by perineal wounds or chronic sinuses. Muscle and myocutaneous flaps can be used to close large defects, increase vascular supply to poorly healing wounds, and provide bulk for sitting. We report 5 cases where the gracilis flap was used to repair large perineal defects. The defects were created after wide perineal excision for recurrent tumours associated with radiation damaged skin (2 cases) and after excision of chronic sinuses complicating the perineal wounds after abdominoperineal excision of the anus for inflammatory bowel disease (3 cases).

A new classification of hepatic territories using intraoperative ultrasound.

Intraoperative ultrasonography is now established as the most accurate technique for detecting and localizing hepatic tumors, be they primary or metastatic. A major problem is the accurate placement of any lesions found by intraoperative ultrasound and, hence, the correlation of the lesions found by ultrasound to the current classification of hepatic segments and to lesions seen by other imaging techniques. This paper outlines an objective and reproducible method of mapping hepatic lesions into territories defined solely by the major hepatic veins and their tributaries. It is a simple technique that can be readily used by any surgeon, which accurately determines the presence, number, size, and site of hepatic metastases.

Vascular complications following orthotopic liver transplantation.

During the first 3 years of the Australian National Liver Transplantation Programme, 51 liver grafts were performed in 46 patients. There were 11 major vascular complications encountered following 10 liver transplants in eight (17%) patients. They caused death in three patients and the need for retransplantation in two others. Hepatic artery thrombosis (HAT) occurred five (10%) times, producing a spectrum of clinical illness ranging from death to an asymptomatic event. Other vascular complications included hepatic artery stenosis not complicated by thrombosis (two), primary (one) and secondary (one) haemorrhage, thrombosis of a mesoportal venous graft (one) and inferior vena caval stenosis (one). Vascular complications are a significant cause of morbidity and mortality following liver transplantation. Predisposing and precipitating factors should be recognized and minimized.

Liver graft revascularization by donor portal vein arterialization following "no touch" donor hepatectomy.

Unsatisfactory immediate function of the transplanted liver together with technical complications contribute to a persisting early mortality for hepatic transplantation in the 20% range. We report our initial clinical experience with methods, one not previously used clinically, that resulted in uniformly well-functioning liver grafts in 11 patients and contributed to a satisfactory success rate for the procedure. Donors were heart-beating. During the donor operation all manipulations of the liver were avoided until after cold preservation, achieved by external cooling at the same time as circulatory interruption, donor exsanguination and perfusion of the liver with cold oxygenated fluid of "extracellular" type. The organs were then gently dissected. At transplantation the livers were revascularized with arterial blood shunted from the recipient iliac artery to the graft portal vein after completion of the suprahepatic IVC anastomosis. The infrahepatic IVCs and hepatic arteries were then joined, the iliac artery shunts discontinued and the portal veins joined. Total ischaemic intervals for the allografts were 3 1/2-8 (average 5). Anhepatic intervals were 1-2 1/4 (average 2). The arterio-portal shunts were operating for 18-85 (mean 46) min. Blood loss and haemodynamic, acid-base and electrolyte abnormalities at revascularization were minimal. All grafts secreted bile immediately and all parameters reflected continuing improvement of liver function thereafter. Nine patients (82%) are alive between 4 and 18 (mean 11) months after transplantation. We conclude that these methods offer effective avoidance of serious organ damage during donor hepatectomy and preservation, reduced allograft ischaemic interval and reduced recipient anhepatic time. They result in avoidance of blood loss at the time of revascularization, together with minimal haemodynamic, acid-base or biochemical changes. In addition, they allow the surgeon to perform and test all anastomoses without time constraints, provide the capability to deal with unexpected complications, and assure good early graft function.