Management of sacrococcygeal pilonidal disease.

OBJECTIVE: Many techniques have been described for the treatment of patients with sacrococcygeal pilonidal disease. No data exists, in relation to this disease within the Kingdom of Saudi Arabia. The aim of this paper is to evaluate our technique retrospectively for management of pilonidial disease with regard to cure and recurrence rates. METHODS: All patients treated at King Faisal Specialist Hospital with either pilonidal abscess or sinus between 1990 and 1998 were identified from the colorectal database and details concerning their presentation, surgery and follow-up were obtained from the patients charts. Both patients with pilonidal sinus and abscess were managed by laying open. Patients were followed until their wounds had healed. RESULTS: Ninety-eight patients, 12 females and 86 males were treated for pilonidal disease in an 8-year period. All patients were managed by laying open. Thirty-one had had previous surgery. Seventy-one presented with pilonidal sinus and 27 presented with pilonidal abscess. The mean length of history prior to presentation was 25 months. Thirty-one patients had an average of 1.6 operations prior to surgery at King Faisal Specialist Hospital. The mean hospital stay was 5.4 days. The average time for healing following laying open was 2.4 months. Five patients developed recurrence following surgery at King Faisal Specialist Hospital 6%. Of the 67 patients who had their primary surgery at King Faisal Specialist Hospital, 2 patients developed recurrence 3%. The mean period of follow up was 6 months range (3-50 months). CONCLUSION: "Laying open" should be the treatment of choice for patients with sacrococcygeal pilonidal disease irrespective of whether the patient presents acutely or electively. Cure rates are high and recurrence rates are low. There is no longer any place for the 2 stage management of pilonidal abscess.

Anastomotic leak in colorectal surgery: a single surgeon's experience.

BACKGROUND: Anastomotic leakage following colorectal resection and anastomosis has been proposed as a colorectal surgical indicator. Leak rates after elective surgery vary and tend to be higher as anastomoses become lower. The present study audits leak rates and outcomes of patients undergoing colorectal surgery, under the care of a single surgeon, in two geographically different centres. METHODS: Patients presenting to the University Colorectal Service in Wellington between 1975 and 1990 and patients presenting to the colorectal service at King Faisal Specialist Hospital (KFSH) between 1990 and 1999 were recorded in computerized databases. These databases were searched for patients who developed anastomotic leakage. The records of patients identified were examined in relation to diagnoses, presentation, primary operation, further surgery performed, and final outcome. RESULTS: Two thousand and 11 patients were entered into the Wellington database and 1,348 were entered into the Riyadh database. Twenty-nine patients with a leaking anastomosis (3.6%) were identified. There were 19 male patients. The postoperative mortality rate in patients who did not leak was 1.7% but in patients who developed a leak after the same operation this rate was 24.1%. Most patients who sustained a leak had an original diagnosis of colorectal cancer. More non-leaking anastomoses were sutured. Sixteen patients with leaks (55.2%) received perioperative total parenteral nutrition (TPN) (9.2% in the no-leak group). Leaking anastomoses were associated with more postoperative respiratory problems (55.2% vs 24.0%) and wound infections (65.5% vs 14.8%). Of the 22 living patients, seven had no surgical intervention, 14 had stomata (two stomata were retained) and one patient with a localized leak was drained percutaneously. Five other patients in addition to having a stoma constructed were drained percutaneously. No patient developed an enteric fistula following leakage. CONCLUSION: Anastomotic leakage may be minimized by ensuring that patients are as fit as possible prior to surgery, stomata are used liberally, particularly in emergency patients, and a good anastomotic technique is utilized at all times. Despite these precautions some patients will still develop a leak and if timely and appropriate action is taken the majority will survive and have their stomata closed.

The cutting seton: an experience at King Faisal Specialist Hospital.

PURPOSE: A 30-percent gas incontinence rate has been reported after the use of the cutting seton in complex anal fistulas. This study was undertaken to determine the morbidity and efficacy of the cutting seton in the management of complex anal fistulas at the King Faisal Specialist Hospital. METHODS: All patients who had a cutting seton inserted in the colorectal unit at King Faisal Specialist Hospital between 1990 and 1998 were identified from a colorectal data base. The charts of these patients were examined and form the basis of this report. Setons were inserted and tied under general anesthesia after the fistula tract had been identified. All fistulas were transsphincteric, and if it seemed that more than 30 percent of the internal sphincter would need to be divided to "lay open" the tract, a seton was used. Fistulas were designated "high" if the internal opening was above the level of the anal crypts. Setons were tightened under general anesthesia at intervals of three to four weeks until cutting was complete. Patients were followed up until wounds had healed and fistula symptoms had resolved. RESULTS: Data from 47 patients were analyzed. The mean duration of disease before surgery was 39.1 months. Twenty-five patients had had previous anorectal abscess drainage. The mean number of previous fistula operations was 2.2. Before seton insertion five patients were incontinent to gas, two to liquid stool, and none to solid stool. Continence status before seton surgery was unknown in 11 patients. There were 16 "high" fistulas. Methylene blue dye was used to identify the internal opening in 14 patients when simple probing failed. Setons were tightened on three or more occasions in 12 patients, twice in 19 patients, and once in 16 patients. Mean perineal wound healing time was six months. The mean length of follow-up was 1.1 years, and during this time one fistula recurred. After treatment a total of 17 patients (36.2 percent) were incontinent to gas, 4 to liquid feces (8.5 percent), and 1 to solid feces (2.3 percent). Four patients complained of soiling. Of previously continent patients, 9.5 percent were significantly incontinent to gas, but in addition 21.4 percent were "occasionally" incontinent for gas. CONCLUSION: The use of the cutting seton resulted in a significant gas incontinence rate of 9.5 percent after a mean follow-up of 1.1 years. Only 1 fistula recurred.

Anal incontinence surgery: a small personal experience.

BACKGROUND: The true incidence of faecal incontinence in Saudi Arabia is unknown and probably relatively few patients seek treatment at the present time. In order to assess the types of treatment available and their outcomes, a retrospective audit of patients presenting at King Faisal Specialist Hospital during an 8-year period has been undertaken. METHODS: Charts were examined in order to identify the cause of the incontinence, the severity and duration of the problem, the clinically determined resting and squeeze pressures, the anatomical muscular defect, the surgery performed, the surgical morbidity, the results of surgery and the length of follow up. RESULTS: Thirty patients (average age 36.9 years) were surgically treated for anal incontinence. Thirteen were females. Previous fistula surgery was the commonest cause for incontinence. Nine patients had generalized sphincter weakness. The average duration of symptoms was 71.6 months. Eighteen patients had overlapping sphincter repairs, of whom eight had wounds that became infected and 13 (72%) patients were 'better'. Two of five patients were 'better' following dynamic graciloplasty. Stomata were constructed in 12 patients and six were closed. Surgery reduced mean incontinence scores (Wexner) from 10.4 to 5.0. CONCLUSION: Overlapping sphincter repair can be safely performed for localized sphincter defects in Saudi Arabia with a high probability of improving continence. In contrast, dynamic graciloplasty is not a suitable operation for patients in this region, where cultural and social habits preclude satisfactory function of the stimulated neosphincter.

Implementation of the World Health Organization 'analgesic ladder' in Saudi Arabia.

The European School of Oncology recently sponsored a symposium at the King Faisal Specialist Hospital in Saudi Arabia entitled 'The modern management of advanced cancer: how to help your patients'. During this symposium, a workshop was organized in order to address the problem of 'the availability and the distribution of narcotics' for patients with advanced symptomatic cancer in the Kingdom of Saudi Arabia. Many country-wide problems were identified including the lack of specific information, religious acceptance and education for patients, health care professionals and government, the availability of medications and access to palliative care. It was suggested that clear protocols for the acceptance of patients into palliative care programmes, the prescribing and delivery of medication, and their availability throughout the country, be established. The goal of allowing patients with advanced cancer to die with dignity and without pain was identified as a worthy one and one that would be appreciated not only by patients themselves but by their relatives, carers, religious leaders and government. The workshop discussed some of the ways of trying to achieve this goal, and its conclusions are reported here.

Diverticular disease: an experience at King Faisal specialist hospital.

BACKGROUND: Diverticular disease of the colon is rarely seen in Saudi Arabia and this paper describes our experience with 16 patients admitted to hospital during an 8-year period (March 1990 - February 1998). PATIENTS AND METHODS: A computerized data base of patients having colorectal surgery was searched to identify patients admitted to the colorectal unit suffering from diverticular disease of the colon or it's complications. The records of these patients were examined and form the basis of this report. RESULTS: Sixteen patients were admitted to the colorectal unit for the management of diverticular disease or it's complications during an 8-year period. One patient presented with a localized abscess which was drained percutaneously. Fifteen patients underwent one or more surgical interventions. There were three female patients. One patient was referred for stoma closure, four for elective surgery and ten with acute perforation of whom one underwent right hemicolectomy for a perforated caecal diverticulum and nine underwent Hartmann's procedure for sigmoid perforation. Two patients required multiple abdominal washouts. Post-operatively two patients developed severe chest infections, one developed renal failure and two urinary infections. Four wounds became infected and two intra abdominal collections were drained percutaneously. No patient died. Eight stomata (89%) were subsequently closed. The mean duration of follow up was 2.7 yr. Four patients were lost to follow up. CONCLUSION: This small series documents the presence of diverticular disease and it's complications in the Kingdom of Saudi Arabia and suggests that the commonest method of presentation may be an acute one. Surgeons must thus be mindful of the condition and take appropriate action. Hartmann's' operation was safe and resulted in a low morbidity and no mortality. 89% of the stomata were closed at a later procedure.

Rectal cancer in the Kingdom of Saudi Arabia: the King Faisal Specialist Hospital experience.

BACKGROUND: No survival data have yet been published from the Kingdom of Saudi Arabia for patients with rectal cancer. The present paper reports experience with these patients over an 8-year period. METHODS: All patients referred to the King Faisal Specialist Hospital (KFSH) between March 1990 and February 1998 for the primary management of rectal cancer were entered into a computerized database. Prior to 1993 patients did not receive adjuvant therapy. Kaplan-Meier survival curves and the log-rank test were used to compare outcome data. RESULTS: There were 70 men (average age: 55.6 years) and 75 women (average age: 52.8 years). Twelve per cent of patients admitted a family history of colorectal carcinoma (CRC). Twenty-seven per cent of tumours were circumferential. Most tumours were larger than 4 cm and the lowest edge of the majority of tumours was less than 6 cm from the anal verge. Fifty-four per cent of tumours were fixed; 69% of patients received either pre-operative or postoperative radiotherapy. A total of 106 patients underwent 'curative' surgery. Equal numbers of patients had abdomino-perineal resection (APR) and anterior resection (AR) of the rectum. Thirty-five patients received blood peri-operatively (APR, 34%; AR, 12%). Major anastomotic leakage following AR occurred in two patients. Two patients died within 30 days of surgery. Ten patients were lost to follow-up. Following curative AR, eight patients had a distal resection margin of < 2 cm and two patients (Dukes' C) developed local recurrence (25%); 37 patients had a margin > 2 cm and seven developed local recurrence (18.9%). A total of 48 patients underwent curative APR, and four patients developed local recurrence (8.3%). Overall local recurrence was tumour stage-dependent (Dukes' B, 8.8%; Dukes' C, 29.3%). Recurrence was local in 13 patients. Pre-operative radiotherapy seemed to reduce average tumour size (3.6 vs 4.3 cm). The crude overall 5-year survival rate was 39%. The 5-year survival rate for patients with Dukes' stage C cancers following 'curative' surgery was 25%. CONCLUSION: Curative surgery can be performed with a relatively low requirement for blood transfusion, a low mortality and morbidity, and comparable outcomes to Western studies in spite of the large, low and often advanced stage of the tumours managed. Local recurrence rates following curative resection and re-anastomosis for low rectal cancers may be reduced by resisting patient pressure to avoid stomata.

Study populations and casemix: influence on analysis of postoperative outcomes.

BACKGROUND: The importance of patient casemix as a determinant of surgical outcome is now being recognized. The present study was undertaken in order to compare the presentation and outcomes in colorectal patients managed surgically by the same surgeon, in the same way, in different settings. METHODS: Colorectal outcome data from the University Department of Surgery in Wellington and the King Faisal Specialist Hospital in Riyadh were analysed in order to determine casemix differences between the two hospitals. Data relating to the type of surgery, the surgeon, the patient's disease, the operation performed and the postoperative complications were compared. Specific colorectal clinical indicators were compared for two commonly performed operations for rectal cancer: anterior resection and abdomino-perineal resection of the rectum. RESULTS: Wellington patients were slightly older and there were more females. Emergency surgery was more frequent in Wellington. Left hemicolectomy, sigmoid colectomy, abscess drainage and pilonidal surgery were more common in Wellington whereas abdomino-perineal resection and anterior resection of the rectum, stoma closure, fistula surgery, seton insertion, restorative proctocolectomy and ileostomy were undertaken more frequently in Riyadh. More complex anal fistulas were managed in Riyadh. Condylomata accuminata, pilonidal abscess, anorectal abscess, rectal prolapse and diverticular disease were rarely seen in Riyadh. There were more postoperative pulmonary and cardiac complications in Wellington. Patients having anterior resection of the rectum were younger in Riyadh and there were proportionally more females. There were some obvious numerical outcome differences in postoperative atelectasis, wound infection, anastomotic leak and deep vein thrombosis rates but none of these reached statistical significance except atelectasis. In Riyadh the usual male-to-female ratio of patients undergoing abdomino-perineal resection was reversed but, again, none of the numerical outcome differences observed reached statistical significance except postoperative atelectasis and intraabdominal abscess. CONCLUSION: Although not statistically significant, the results of the present study suggest that when the same surgeon operates using the same technique in different communities, the outcomes may be different. Care should thus be taken when comparing different populations with different casemixes before definitive conclusions are made in comparative studies.

Unusual 'recurrence' sites for colorectal cancer.

Five patients are reported. Four underwent major 'curative' restorative colorectal resections and developed perineal 'recurrence', 2 developed 'recurrence' in the distal ends of previously identified fistulae in ano and 2 developed 'recurrence' at the site of a previously performed haemorrhoidectomy. The fifth patient developed metastasis to a fistula track prior to surgical intervention. The danger of implantation of exfoliated tumour cells in patients with distally situated 'raw' mucosal sites is recognized and anorectal procedures should not be performed prior to resection. Minor anorectal procedures should not be performed at the same time as colorectal resections for carcinoma in these patients either. Some 'recurrences', such as those described in this paper, may be inevitable and in fact really represent preoperative metastases. Routine flexible sigmoidoscopy prior to the performance of any anorectal procedure might identify patients at risk of such 'recurrences' but this may not be cost-effective.

Dynamic graciloplasty: a small and salutary experience.

BACKGROUND: The Colorectal Unit at the King Faisal Specialist Hospital and Research Centre was one of 12 centers involved in the first international multicenter trial of dynamic graciloplasty. Some complications and problems related to the procedure were specific to Saudi Arabia, and this paper documents this experience in more detail. PATIENTS AND METHODS: Patients with a generalized anal sphincter weakness were offered dynamic graciloplasty. Prior to surgery, patients underwent manometric examination of their sphincters. A right gracilis transposition was undertaken. After six weeks, a pulse generator was implanted and electrodes were inserted. The stimulation program commenced four weeks later. The neosphincter was magnetically controlled to allow defecation. Patients were followed at 3-monthly intervals to assess clinical progress. RESULTS: Five patients (3 males and 2 females) were considered to be suitable for the procedure. One patient developed an infection of the thigh wound which resolved without drainage. There was no other surgical morbidity. Mean resting (26.4 mm Hg) and "squeeze" (51.4 mm Hg) pressures prior to surgery were low. Following implantation, mean resting and "squeeze" pressures rose during training in 4 patients (48.5 and 100.8 mm Hg, respectively). Two patients maintained satisfactory clinical and manometric function at 6 and 5 years' follow-up. One patient ceased to have any function in the transposed muscle and refused a further graciloplasty four years after graciloplasty. Another patient avulsed the leads and the transposed tendon on two occasions, and failed to heed advice given regarding posture and sitting. The final patient had an unsatisfactory wrap because of massive peri-rectal fibrosis. There was a 50% reduction in bowel frequency in the two patients in whom the procedure was successful. CONCLUSION: The technique requires a high level of patient cooperation, but should be available in specialized centers for the management of patients with refractory anal incontinence.

Restorative proctocolectomy--a nine year experience at the King Faisal specialist hospital.

INTRODUCTION: Inflammatory bowel disease and Familial Adenomatous Polyposis (FAP) are relatively uncommon in Gulf Arabs. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical method for treating patients with mucosal ulcerative colitis (MUC) and FAP. This paper documents a small experience with this operation in Saudi Arabia. METHODS: The charts of all patients who had either MUC or FAP and in whom an IPAA had been performed were identified and were examined in order to determine patient demographics, timing and staging of operation, operative and long term morbidity and mortality and pouch function. RESULTS: Thirty patients underwent IPAA. There were 16 males. 29 pouches were J-pouches. 1 patient was lost to follow up. Surgery was performed for fulminating MUC in 9 patients, failed medical treatment in 12, FAP in 7 and megacolon in 2. An emergency-three stage IPAA was performed in 10 patients. 3 patients received perioperative TPN. 17 were on steroid medication. 12 developed transient anastomotic stricture. 8 developed small bowel obstruction during follow up but none needed further surgery. 1 patient developed 'pouchitis'. Two pouches were removed. The mean daily and nocturnal bowel frequency was 6 and 2 motions per day. 6 patients suffered nocturnal leakage. CONCLUSION: The operation of restorative proctocolectomy can be performed safely, for the few patients who needed the operation in Saudi Arabia.

Colorectal operative experience in general surgical training.

BACKGROUND: Surgical trainees often feel that their operative training is inadequate--trainers usually do not share this view. METHODS: The distribution of colorectal operative surgical workloads between consultants and trainees was examined over a 15-year period in the Colorectal Service at the Wellington School of Medicine. RESULTS: Consultants performed 947 operations and trainees performed 1012 operations. The average age of patients operated on by trainees was lower than that of those operated on by consultants. Trainees performed more emergency surgery. Anorectal surgery, except fistula surgery, was more commonly performed by trainees, whereas abdominal colorectal surgery was more commonly performed by consultants. Trainees had lower postoperative morbidity and mortality rates. The diseases predominantly treated by consultants and trainees differed. Twenty-four percent of patients with colorectal cancers and 25% of patients with diverticular disease were managed operatively by trainees. Yearly trainee workloads for minor anorectal conditions were similar to those of trainees in the USA. CONCLUSION: Although this small colorectal audit provides some information about trainees' operative experience, until all surgical procedures performed by all surgical trainees are accurately audited and criteria for adequacy of operative training are clearly stated, it will not be possible to say whether our training programs provide adequate operative training or not.