Overlapping sphincteroplasty: does preservation of the scar influence immediate outcome?

BACKGROUND: The importance of the overlapping scar in an anterior sphincteroplasty is often emphasized. The aim of this study was to identify the tissue type used in overlapping sphincter repair based upon ultrasound images, and to correlate these results with the immediate clinical outcome. METHODS: Data were collected prospectively on all patients with faecal incontinence who underwent anterior overlapping sphincteroplasty between June 1998 and May 1999. Continence was assessed by a standardized incontinence score ranging from 0 to 20. Pre-operative ultrasound images were compared to intraoperative ultrasound findings for each patient. In each case the surgeon performed an overlap of what was grossly felt to represent scar after which a single blinded observer performed intraoperative ultrasound. The degree of overlap was measured and classified as hyperechoic over hyperechoic (muscle over muscle; Type 1), hyperechoic over or under hypoechoic (muscle over or under scar; Type 2), hypoechoic over hypoechoic (scar over scar; Type 3). The patient follow-up included incontinence score that was obtained by telephone interview; suboptimal outcome was considered as an incontinence score >/= 6. Statistical analysis was performed using the Mann-Whitney test and Wilcoxon matched-pairs test. RESULTS: Fourteen female patients with a mean age of 51.6 (range 28-79) years were evaluated. The mean pre-operative incontinence score was 17.1 (range 7-20) and 13 of the 14 (93%) patients had an incontinence score >/= 15. All pre-operative ultrasound images were hypoechoic which correlated with the surgeon's intraoperative findings of scar. The operative appearance included two Type 1, four Type 2, and eight Type 3 images. Larger pre-operative ultrasound image defects were statistically significantly related to intraoperative Type 3 ultrasound images. At a mean follow up of 7.5 (range 2-16) months the mean postoperative incontinence score was 4.5 (range 0-12). In patients with Type 1 and Type 2 images, the mean postoperative score was 8.6 (range 4-12) whereas in patients with Type 3 it was 1.3 (range 0-5) (P < 0.003); 7 of the 8 patients in Type 3 (87.5%) had an incontinence score

Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation.

In a randomised, double-blind study, we investigated rapid extension of epidural analgesia to surgical anaesthesia for emergency Caesarean section. Parturients receiving epidural analgesia in labour who subsequently required Caesarean section were given a test dose of 3 ml lidocaine 2% with epinephrine 1 : 200 000, followed 3 min later by 12 ml lidocaine 2% with epinephrine 1 : 200 000 and fentanyl 75 microg, to which was added 1.2 ml sodium bicarbonate 8.4% (bicarbonate group; n = 20) or saline (saline group; n = 20). Mean (SD [range]) time to surgical anaesthesia was less in the bicarbonate group (5.2 (1.5) [2-8] min) than the saline group (9.7 (1.6) [6-12] min; mean difference 4.5 min (95% CI 3.5-5.5) min; p < 0.001). Maternal side-effects and neonatal outcome were similar between groups. We conclude that pH-adjusted lidocaine 2% with epinephrine and fentanyl is effective for rapidly establishing surgical anaesthesia in patients with a functioning epidural catheter for labour who require emergency Caesarean section.

Staged excision and split-thickness skin graft for circumferential perianal Paget's disease.

PURPOSE: This study was designed to describe a surgical technique for the treatment of circumferential Paget's disease. METHODS: A search of our computerized patient registry was undertaken, and case records for those patients with perianal Paget's disease were systematically reviewed. RESULTS: Between July 1993 and October 1998, four patients with perianal Paget's disease were identified. Circumferential lesions were identified in three of the four patients. Wide local excision was considered the procedure of choice. All patients underwent a two-staged excision using split-thickness skin graft reconstruction. A similar second stage was performed six to eight weeks later; the other half of the circumference was excised and grafted. No patient had a protective stoma. Graft survival was 100 percent for two patients (four operations) and 80 percent and 70 percent for the other two patients (two operations). The remaining surface healed successfully by secondary intention. In one patient, residual disease was positive at one margin, and a third local excision and split-thickness skin graft was performed. Hospital stay ranged from five to nine days for each procedure. There were no major complications; one patient developed a mild anal stenosis three months after the second procedure and was successfully medically treated. CONCLUSIONS: Staged excision and split-thickness skin graft is a viable option for the treatment of circumferential perianal lesions. It carries a minimal morbidity and no observed mortality, the functional result is good, and it is technically simple compared with myocutaneous grafts. Moreover, a stoma is not required.

Does limited placement of bioresorbable membrane of modified sodium hyaluronate and carboxymethylcellulose (Seprafilm) have possible short-term beneficial impact?

PURPOSE: The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity. METHODS: All patients who had Seprafilm placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fisher's exact test was used to compare gender distribution, nature of diagnosis (inflammatory vs. noninflammatory), and urgency of surgery (elective vs. emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Student's t-test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan-Meier product limit method and log-rank test. RESULTS: Two hundred fifty-nine patients in whom Seprafilm was placed were compared with a well-matched control cohort of 179 patients. The two groups did not differ in gender or age. One-half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm group and 12 intestinal obstructions in 11 patients in the control group at a follow-up period of 65 months in the Seprafilm group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm (3.4 percent) and control (1.1 percent) groups. CONCLUSION: During short-term follow-up in this nonprospective, nonrandomized study, limited placement of Seprafilm did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long-term, prospective, randomized trial is underway to elucidate these issues.

How does a change in the administration method affect the reliability of the COOP/WONCA Charts? World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians.

BACKGROUND: An interviewer is often needed to administer the COOP/WONCA Charts to Chinese patients, and this may affect the reliability of results. OBJECTIVES: We aimed to find out the reliability of the COOP/WONCA Charts administered by an interviewer, and whether a change in the interviewer or administration method would affect the results. METHODS: We carried out a cross-sectional test-retest study on 487 Chinese adult patients attending a family medicine clinic in Hong Kong. The COOP/WONCA Charts were administered by the same interviewer, two different interviewers or self-completion and interviewer administration, on test and retest. The random, inter-observer and inter-method variances were compared with the inter-subject variance. The reliability coefficient of each COOP/WONCA Chart was calculated for each method of administration. RESULTS: Random errors could change the scores by 0.57-1.04, inter-observer variations could change the scores of four charts by 0.72-0.80, and a change in the method could change the physical fitness score by 1.79 and the daily activities score by 1.31, on a five-point scale. The reliability coefficients of the six COOP/WONCA Charts were 0.68-0.92 for one interviewer, 0.59-0.82 for two interviewers and 0.46-0.81 for two methods. CONCLUSION: The Chinese COOP/WONCA Charts were reliable in detecting real differences when administered by an interviewer. A change in the method of administration significantly decreased the reliability of the results. The use of more than one method of data collection in the same survey should be discouraged.

How useful is colonoscopy in locating colorectal lesions?

BACKGROUND: It is important to establish the precise location of a colorectal lesion preoperatively. We used a model based on colorectal cancer to assess the efficacy of colonoscopy in locating these lesions. METHODS: We retrospectively analyzed all consecutive new colorectal cancer cases at the Department of Surgery, United Christian Hospital, Hong Kong, in 1995. RESULTS: Of the 123 cases reviewed by us, 84 cases satisfied the analysis criteria. The overall accuracy was 81%. It was especially high in the rectosigmoid region (93%) and descending colon (100%). The overall predictive power was 83%. It was especially high in the right-sided colon (100%) and the rectosigmoid region (93%). CONCLUSIONS: We conclude that colonoscopy is an accurate means for locating lesions in the upper rectum and sigmoid colon. It is also very predictive of lesions in the upper rectum, sigmoid colon, and right-sided colon.

Neurotrophin-4/5 treatment reduces infarct size in rats with middle cerebral artery occlusion.

The aim of this study was to determine whether neurotrophin-4/5 (NT-4/5) treatment alters infarction volume following permanent focal cerebral ischemia in the rat. Permanent focal cerebral ischemia was produced in adult male rats by intraluminal occlusion of the right middle cerebral artery. NT-4/5 was administered intraventricularly one day before and immediately following occlusion. Rats were sacrificed at 1, 4 and 7 days after occlusion. NT-4/5 treatment reduced infarction volume by 34% when compared to control rats 1 day after occlusion. Infarction volume was unaltered by treatment 4 to 7 days after occlusion. Middle cerebral artery occlusion led to a significant reduction in levels of mRNAs coding for catalytic and truncated TrkB receptors. This expression was unaffected by NT-4/5 treatment.