The social, psychological, emotional morbidity and adjustment techniques for women with anal incontinence following Obstetric Anal Sphincter Injury: use of a word picture to identify a hidden syndrome.

BACKGROUND: To identify the emotional, social and psychological consequences and recovery process of anal incontinence (AI) following obstetric anal sphincter injuries (OASIS) and explore if this can be identified as a recognisable syndrome with visual representation. METHODS: A qualitative approach was adopted for this study. Data derived from case studies (n = 81) and interviews (n = 14) with women with AI after OASIS was used to identify the emotional, social and psychological consequences of AI after OASIS. Keywords and synonyms were extracted and the power of these statements displayed as a 'word picture'. The validity and authenticity of the word picture was then assessed by: a questionnaire sent to a group of mothers who had experienced this condition (n = 16); a focus group attended by mothers (n = 14) and supported by health professionals (n = 6) and via interviews with health professionals (n = 12) who were involved with helping mothers with AI following OASIS. RESULTS: Women with AI resulting from OASIS have a specific syndrome - the 'OASIS Syndrome' - which we have uniquely visualised as a 'word picture'. They feel unclean which results in dignity loss, psychosexual morbidity, isolation, embarrassment, guilt, fear, grief, feeling low, anxiety, loss of confidence, a feeling of having been mutilated and a compromised role as a mother. Coping relies on repetitive washing (which may become a ritual), planning daily activities around toiletry needs, sharing, family support, employment if possible and attention to the baby. Recovery and healing is through care of the child and hope generated by love within the family. CONCLUSIONS: This study has identified a previously unrecognised 'OASIS Syndrome' and, by way of a new and unique 'word picture', revealed a hidden condition. There should be greater awareness by the public and profession about the 'OASIS Syndrome' and a mechanism for early identification of the condition and referral for management. This, if successful, would overcome the barrier of silence which surrounds this currently unspoken taboo.

Peritonitis following stapling of a flush ileostomy.

Peritonitis following staple stabilization of a flush ileostomy has not yet been reported in the literature. We report a case of iatrogenic injury to a loop of the ileum in an unrecognized parastomal hernia which caused peritonitis after stapling of a flush ileostomy.

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India.

OBJECTIVE: Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts. METHOD: All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database. RESULTS: One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% (P < 0.001)) and low rectal tumours (63.0% vs 50.0%) (P = 0.043), but were equally likely to undergo curative surgery compared to the older group (P = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0-2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) (P = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) (P = 0.014). CONCLUSION: The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.

Early results of immediate repair of obstetric third-degree tears: 65% are completely asymptomatic despite persistent sphincter defects in 61%.

OBJECTIVE: The outcome of immediate repair of obstetric third-degree tears is poorly documented. Immediate repair may give better functional results than delayed repair because scarring is reduced. This aim of this prospective study was to examine the early outcome of immediate repair of third-degree tears. METHOD: A total of 121 women who had immediate repair of obstetric third-degree tears underwent interview, anal ultrasonography and anorectal physiology. RESULTS: At review, 79 (65%) were completely asymptomatic (score = 0), 23 (19%), had minor flatus incontinence or mild urgency causing no compromise to their quality of life (score 1-4), and 19 (16%) had clinically embarrassing faecal incontinence (score 5-24). Thirty-nine (32%) had an intact internal anal sphincter (IAS) and external anal sphincter (EAS) (i.e. a successful repair), eight (7%) had a defect in the IAS alone but the EAS was intact (i.e. a successful repair but a residual IAS defect), 43 (35%) had a residual defect in the EAS alone (IAS intact) and 31 (26%) had a persistent defect in the IAS and EAS. Residual defects in either or both of the sphincters were associated with a significantly higher incidence of abnormal resting and squeeze anal pressures. Anal manometry had no correlation with symptoms. The highest proportion of severe incontinence was in those with an IAS defect alone (37%) and when there was a residual IAS and EAS defect (24%). Only 2 of 39 (5%) with an intact IAS and EAS had severe incontinence and only 8 of 43 (18%) with a residual EAS defect alone had severe faecal incontinence. CONCLUSION: These results indicate a good outcome following immediate repair of third-degree obstetric tears and emphasize the role of the IAS in providing continence.

The outcome of surgery in fulminant Clostridium difficile colitis.

BACKGROUND: The clinical presentation of Clostridium difficile infection ranges from asymptomatic carriage, colitis with or without pseudomembranes, to fulminant colitis. Although not common, fulminant C. difficile colitis can result in bowel perforation and peritonitis with a high mortality rate. Colectomy is often indicated in these cases. METHODS: We retrospectively analysed the outcome of 14 patients who underwent surgery for fulminant C. difficile colitis in the period 1996-2003 in our Unit. RESULTS: The indications for surgery were systemic toxicity and peritonitis (n = 10), radiological and clinical evidence of progressive toxic colonic dilatation (n = 3) and progressive colonic dilatation with bowel perforation (n = 1). C. difficile infection as the cause of colitis was diagnosed pre-operatively in seven (50%) patients, six of whom underwent a total colectomy and one a right hemicolectomy. Overall mortality in our series was 35.7%. Total colectomy was associated with a lower mortality rate of 11.1% (1/9) when compared with left hemicolectomy was 100% (4/4) (P = 0.01). One patient who underwent a right hemicolectomy (on the basis of deceptively normal external appearance of the rest of the colon intra-operatively) survived after a prolonged hospital stay. CONCLUSIONS: Early or pre-operative microbiological diagnosis of C. difficile infection can be difficult in patients with a fulminant presentation. Those patients with C. difficile colitis, who develop signs of toxicity, peritonitis or perforation, should undergo a total colectomy as the operation of choice.

Pedicled flaps in the treatment of nonhealing perineal wounds.

INTRODUCTION: A persistent sinus is an annoying complication following proctectomy. We examined the experience of a single colorectal surgeon in treating this condition using pedicled flaps. METHODS: Case note review of all patients undergoing gracilis muscle transposition, Rectus abdominis muscle flap or omental flap for persistent perineal sinus. RESULTS: Seventeen patients were identified: seven had gracilis muscle transposition, eight had omental transposition and two had a rectus abdominis flap. 13/17 patients who underwent a flap had a persistent sinus following proctectomy for Inflammatory bowel disease. Four patients who had a gracilis muscle transposition achieved healing. Seven out of eight patients had good results with omental transposition. One patient did well after a rectus abdominis flap. CONCLUSIONS: A gracilis transposition is a relatively simple operation with minimal morbidity useful for superficial sinuses not requiring a muscle bulk. A rectus abdominis flap is a more complex specialized procedure with better results especially in dealing with larger cavities but it may compromise future stoma sites. Omentoplasty has excellent results, but is only available in some patients.

Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease.

OBJECTIVE: Crohn's disease is a chronic inflammatory, panintestinal disease of uncertain aetiology. The recurrence rate of Crohn's disease, often taken as the time when further surgical procedure is undertaken, has been reported to be as high as 76% in 10 years. The site of the disease has not yet been associated with the recurrence rate of Crohn's disease. The aim of the study was to compare the outcome of patients who were surgically treated for jejunal Crohn's disease to those whose diseases was confined to the ileocaecal region. METHOD: The information was tracked from our database of 724 surgically treated Crohn's disease patients between 1943 and 2002. Twenty-eight patients with jejunal Crohn's disease at their first operation (12 jejunum alone, 16 also involving other sites) were identified. For each of these patients, 3 patients with ileocaecal Crohn's, matched for age, sex, and smoking habits (n = 84) were identified as controls. RESULTS: The median age in both groups was 21 years (range 16-52 years) with a median follow-up period of 19 years. The 3, 5 and 10 years re-operation rate for the groups with jejunal disease were 43%, 50% and 61% compared to 22%, 30% and 51% with ileocaecal disease, respectively. CONCLUSIONS: The presence of jejunal Crohn's disease is associated with a higher rate of early disease recurrence compared to ileocaecal disease but long-term recurrences rate do not differ significantly.

Ileostomy for constipation: long-term postoperative outcome.

BACKGROUND AND AIMS: Idiopathic constipation is a rare indication for ileostomy construction. The aim of the study was to evaluate the success of ileostomy in treatment of severe constipation. Also to analyse the surgical complications and re-operation rate to identify any factors potentially predictive of outcome. PATIENTS AND METHODS: This retrospective study analysed the long-term outcome of 24 ileostomies constructed for constipation. The ileostomy construction was performed in 13 patients during large bowel/rectum resection, in 6 after a full laparotomy and in 5 through an abdominal wall trephine alone. We analysed the surgical complications and the re-operation rate according any factors potentially predictive of outcome. RESULTS: One (4%) patient had persistent constipation after stoma creation. Surgical complications occurred in 11 (46%): retraction in 6 (25.0%), peristomal sepsis in 3 (12.5%) and parastomal hernia in 2 (8.1%). Refashioning of the stoma was necessary in 7 (29%) patients. Previous abdominal surgery, end ileostomy, ileostomy constructed after large bowel resection or laparotomy were associated with a significantly higher incidence of stomal complications while age, duration of follow up, major complication and ileostomy created after bowel resection were associated to a significantly higher re-operation rate (P < 0.05). Multivariate analysis identified end ileostomy and ileostomy created after bowel resection as independent risk factors for surgical complication and re-operation, respectively (P < 0.05). CONCLUSIONS: Ileostomies were associated with a high frequency of complications, but most could be managed by minor surgical interventions. Patients who are considered for an ileostomy for severe idiopathic constipation should, where possible, have a loop ileostomy through a trephine rather than a laparotomy.

Importance of evacuatory disturbance in evaluation of faecal incontinence after third degree obstetric tear.

OBJECTIVE: To correlate anorectal function including rectal evacuation with anorectal physiology and endoanal ultrasound in women with third degree obstetric anal sphincter injury repaired at the time of delivery. PATIENTS AND METHODS: Forty-four women with repaired third degree tears underwent anorectal physiology, anal ultrasonography and clinical assessment using the St. Marks incontinence score (0-24). Evacuatory disturbance was assessed by questionnaire. RESULTS: There was a significant correlation between disturbed evacuation and incontinence symptoms (P=0.030). There was also a significant correlation between disturbed evacuation and internal anal sphincter (IAS) injury (P=0.026), but there was no correlation with external anal sphincter (EAS) injury. There was a correlation between disturbed evacuation and low resting anal pressure (P=0.013). Although IAS defects were associated with low anal pressure, only the correlation with Maximum Squeeze Pressure reached statistical significance (P=0.018). CONCLUSION: Women with evacuatory disturbance after repaired third degree tears have a greater level of incontinence than those whose emptying is normal. This association is related to internal sphincter injury and reduced anal sphincter pressures.

Long strictureplasty is as safe and effective as short strictureplasty in small-bowel Crohn's disease.

BACKGROUND: For the past 20 years it has been shown that intestinal strictureplasty is safe and effective in the management of short strictureplasty. Long strictureplasty (> 20 cm) may be an alternative to resection in some patients, especially in diffuse disease or after previous extensive resections. We reviewed the outcome of long strictureplasty for Crohn's Disease, to examine safety and recurrence rates, compared with conventional short strictureplasty. METHODS: Sixty-two patients have undergone single strictureplasty for jejunoileal Crohn's disease since 1974. Median follow-up was 121 (range 7-253) months. Twenty-one operations involved a single long strictureplasty, and 41 operations had a single short strictureplasty. RESULTS: No significant differences were identified between the groups. The postoperative complications in long strictureplasty included 2 abscesses only and after short strictureplasty there was one anastomotic leak and one postoperative abscess. The median hospital stay was 10 days after long strictureplasty and 9 days after short strictureplasty. Three-, 5- and 10-year disease-free rates for long and short strictureplasty, respectively, were 3-year 80.4% and 62.1%; 5-year 55.2% and 49.8% and 10-year 49.1% and 33.5% (NS). CONCLUSIONS: These data indicate that long strictureplasty is safe and produces equivalent results to conventional (short) strictureplasty.

Public awareness of risk factors and screening for colorectal cancer in Europe.

Colorectal cancer (CRC) is the commonest site for malignancy in Europe. The Commissioner for Health wishes to promote screening for colorectal, breast and cervical cancer in Europe. The aim of this study was to assess public knowledge of CRC in Europe and likely take up of free screening. To this end 20710 members of the public from 21 European countries were interviewed by means of a regular survey amongst consumers (Omnibus survey) using 13 stem questions. Forty-eight per cent thought the population were at equal risk of CRC, only 57% were aware of age and 54% of family history as risk factors. Although 70% were aware of dietary factors, only 30% knew that lack of exercise might be a risk factor. Only 51% had knowledge of CRC screening but 75% were 'very', or 'quite interested, in taking up faecal occult blood (FOB) screening if offered free. Barriers to screening were lack of awareness of risk (31%), youth (22%) and an un-anaesthetic test (19%). There was a big cultural difference in willingness of the public to discuss bowel symptoms: there was a major barrier in Finland (91%), Britain (84%), Luxembourg (82%), Poland (81%) and Portugal (80%); less of a barrier in Spain (49%), Italy (44%) and Iceland (39%). In conclusion, the challenge of achieving high compliance for CRC screening must be a major objective amongst EU member states and non-aligned countries of Europe in the next decade, because it is known that the non-compliant group are those at greatest risk of death from CRC. This study has shown that awareness of CRC is low in Europe and that an educational programme will be essential to achieve high compliance for CRC screening as a means of reducing deaths from bowel cancer.

Reliability of radiographic measurement of small intestinal length.

OBJECTIVE: The capacity for absorption of nutrients after small intestinal resection is related to the remaining length of intestine, and short bowel syndrome has major implications. Accurate pre-operative determination of bowel length may be useful in conditions where further resection of small bowel is contemplated. The aim of this study is to evaluate the accuracy of small bowel length measured by barium follow-through (BaFT) examination. PATIENTS AND METHODS: Twenty-two patients underwent both intra-operative measurement of small bowel length, and BaFT examination where length was measured using an opisometer. RESULTS: The difference between operative and radiological measurement (mean +/- standard deviation: 15.7 +/- 16 9%) was least in those with the shorter small intestine (overall variation: r = 0.703, P < 0.01, regression coefficient: -0.118, intercept: 15.1). There was no difference in whether BaFT was performed pre or postoperatively. CONCLUSION: Assessment of small bowel length by BaFT radiography is accurate, particularly in those with shorter small bowel lengths.

Quality of life in patients with an ileostomy.

AIM: Temporary or permanent ileostomy is a common procedure in colorectal surgery. Our aim was to assess the impact of ileostomy on quality of life and the relevant risk factors. METHODS: A 33-question questionnaire was sent, by mail, to 74 patients (over 70, between 70 and 50 and under 50 y old). The questionnaire explored 5 parameters of function: systemic symptoms, bowel symptoms, functional impairment, social impairment and emotional impairment. Further questions investigated the need for a nurse or relative to assist with management of the stoma, the frequency of changing the bag and the appliance, diet and the ability of patients to attend their normal daily activity. RESULTS: Thirty-four patients completed the questionnaire. The final quality of life score was similar for all the 3 age groups but elderly patients needed more assistance in the stoma management. The quality of life scores in males patients were significantly better than in females. No statistically significant difference was observed comparing loop ileostomy versus end ileostomy and Crohn's disease versus ulcerative colitis. CONCLUSIONS: Quality of life is not influenced by age, underlying inflammatory disease or type of ileostomy. Males report less impact on quality of life than women.

Duration of pneumoperitoneum on chest radiograph after open colorectal surgery.

BACKGROUND: Postoperative pneumoperitoneum on a plain chest radiograph is a potentially important medicolegal document of possible complication. However, pneumoperitoneum may be observed without significance after intra-abdominal procedures. METHODS: Between April 2001 and March 2002, 204 consecutive open laparotomies for colorectal surgery were studied. Sixty-three patients had 97 chest radiographs taken before the twenty-fifth postoperative day. RESULTS: Only one patient had subdiaphragmatic air (height >20 mm) on the tenth postoperative day associated with a visceral perforation. Normal subdiaphragmatic pneumoperitoneum was observed on 11 films in 8 patients (13%). Small amounts of air (<15 mm high) were observed in 7 (15%) of 47 radiographs on days 0-5, in 4 (18%) of 25 radiographs on days 6-10, but in no radiograph of 24 after day 10. CONCLUSIONS: Subdiaphragmatic pneumoperitoneum less than 20 mm high is often observed between the sixth and tenth postoperative days, without clinical importance.

Is colonoscopic screening of a low-risk (normal) population ethically justifiable?

This report summarizes the arguments for and against colonoscopic screening of a low-risk population for colorectal cancer. The strongest argument in favor of colonoscopy is that colonoscopy rarely misses an existing colorectal neoplasia and its precursor lesions and that procedural side effects are rare. In contrast, the combination of fecal occult blood test plus sigmoidoscopy leaves 10-15% of advanced neoplasms in the proximal colon undetected. However, colonoscopy is costly and the health care systems of only few European countries refund the respective costs. In addition, there is presently not sufficient manpower available to deliver colonoscopy to the public starting at the age of 50 in a 1:10 yearly frequency. Compliance to the procedure is very low even in countries which refund screening costs. Therefore, promotion of colonoscopy as the presently most effective screening procedure depends mainly on major educational efforts within the public to increase compliance as well as on the readiness of European health care systems to cover the respective costs.