Stoma reversal in functional bowel disease: managing patient choice.

INTRODUCTION: This study aims to assess the rate of stoma reversal in patients who have undergone stoma formation with permanent intent for functional bowel disorder. We also assessed the incidence of malignancy in defunctioned bowel. METHODS: This is a retrospective study of the outcomes of patients undergoing planned permanent stoma formation for functional bowel disorder over a 10-year period at a single tertiary centre. RESULTS: Of 92 patients included in the study, 11 (12%) requested and underwent stoma reversal following stoma formation for functional bowel disorder. Of 84 patients with defunctioned bowel left in situ, two (2%) developed bowel malignancy during our study period. CONCLUSIONS: Stoma formation may be necessary for patients with incontinence and constipation when conservative treatments fail. Some patients have very firm views about the need for a stoma, but a significant proportion of patients do not cope with a stoma and request reversal, therefore patient selection and pre-procedure counselling are important. The risk of developing malignant disease in the defunctioned colon is potentially significant, and consideration should be given to appropriate surveillance in this group of patients. Evidence for stoma formation in functional gastrointestinal disorders is lacking; this study reports outcomes in a large cohort of patients over a long period, and highlights areas where further research and practice guidelines are needed. If large numbers of patients are undergoing stoma reversal posing significant mortality and morbidity risks, this suggests that patient selection and preoperative counselling need refinement.

Use of the internet by colorectal cancer patients.

OBJECTIVE: To identify the frequency of Internet use by colorectal cancer patients. MATERIALS AND METHODS: Fifty patients interviews. RESULTS: Only four patients (8%) had used the internet to access information about colorectal cancer though 36% would have used it if a site had been recommended. CONCLUSION: The Internet is a resource rarely used by patients but there is potential for its use as an adjunct to written and verbal information.

Career intentions and prospects of basic surgical trainees in the Northern Region of England.

OBJECTIVE: To determine the seniority and career intentions of doctors in posts recognised for basic surgical training in the Northern Region of England and to relate it to the number of specialist registrar posts available. METHODS: Postal questionnaire to and telephone interviews with 270 doctors. The main outcome measures were: demographic details, career stage, and intentions regarding subspecialties of choice. RESULTS: Of the post-holders, 171 (63%) intended to pursue a surgical career and, of these, 69% (118/171) were graduates of British universities. Of these 171, 28% (48) were uncertain of their subspecialty of choice and 10% (17) intended to work abroad. The overall ratio for SHO:SpR posts was 1.6:1 for this region and 40% of all basic surgical trainees were in favour of a specialist training programme after PRHO. CONCLUSIONS: Planning for surgical training and workforce needs to be supported by information about trainees' career plans and prospects.

Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination.

PURPOSE: Retroflexion of the endoscope during rectal examination may increase diagnostic yield but is not routinely performed because of concerns about safety and a lack of appreciation of its importance. The purpose of this study was to examine the yield, safety, and tolerance of endoscopic rectal retroflexion. METHODS: Prospective cohorts of subjects undergoing unsedated screening flexible sigmoidoscopy were examined with and without routine retroflexion. Pain scores were recorded. RESULTS: A total of 526 subjects (mean age 60 (range, 55-66) years) underwent flexible sigmoidoscopy in the first period when the endoscope was not routinely retroflexed. Of these, 480 (mean age 60 (range, 55-66) years) were subsequently examined with routine retroflexion. Retroflexion was impossible in 17 subjects (3.5 percent) because of discomfort. In the second group, 12 subjects (2.5 percent) had polyps in the lower rectum seen only on retroflexion. Of these, eight had metaplastic and four had adenomatous polyps (3 tubular <5 mm, 1 tubulovillous 15 mm). There was no difference in mean pain scores between the groups (no retroflexion = 2.13, retroflexion = 2.18). CONCLUSION: With an adenoma pick-up rate of 8 to 12 percent for screening flexible sigmoidoscopy, retroflexion increases adenoma detection by approximately 1 percent without adverse effects and should be an integral part of flexible sigmoidoscopy.

Blind percutaneous insertion of Hickman lines by a specialist team.

BACKGROUND: Long-term intravenous lines for the delivery of chemotherapy can be inserted by the percutaneous route or under direct vision by surgical exploration. Though the percutaneous route is widely used, many centres still employ a surgical approach. This study evaluates the safety of the blind percutaneous approach. METHOD: Prospective records were kept of all Hickman lines inserted on the oncology unit of a large teaching hospital. RESULTS: 127 consecutive lines were inserted in 115 adults by a single surgeon over a 30 month period using a blind percutaneous approach. There were 4 complications of insertion: 2 pneumothoraces (1.6%), 1 arrhythmia (0.8%) and bleeding from the subcutaneous tunnel (0.8%). Only 1 line had to be removed in the first 14 days because of hub fracture and leakage. CONCLUSIONS: Percutaneous insertion of Hickman lines using the blind technique is associated with a low incidence of complications when performed by an experienced operator.

How to alter surgical practice? The use of guidelines to encourage day-case haemorrhoidectomy.

BACKGROUND: Day case haemorrhoidectomy has been shown to be safe and acceptable to patients. The best way to introduce such evidence into clinical practice remains unclear: The aim is to assess the effectiveness of guidelines on the introduction of day-case haemorrhoidectomy in a general surgical unit. METHODS: Prospective audit of day-case haemorrhoidectomy and retrospective review of in-patient procedures. The effectiveness of guidelines in encouraging day-case haemorrhoidectomy is assessed by analysis of avoidable admissions. RESULTS: In the year prior to introduction of the guidelines 75 patients had elective haemorrhoidectomy, none as day-cases. In the year following the introduction of the guidelines 80 patients had elective haemorrhoidectomy, 35 (44%) as day cases. There were no complications or re-admissions. Of the 45 in-patients 31 (69%) were eligible for day surgery. CONCLUSIONS: The establishment of clear guidelines and their dissemination results in significant changes in practice. However, audit has demonstrated that alternative strategies are needed to encourage changes in clinical practice.

Glutaraldehyde as a possible cause of diarrhoea after sigmoidoscopy.

BACKGROUND: An outbreak of proctitis at the start of a colorectal cancer screening programme utilizing flexible sigmoidoscopy prompted scrutiny of the incidence of this complication and the role of glutaraldehyde in its aetiology. METHODS: Questionnaires completed 1 day and 3 months after sigmoidoscopy were reviewed for 388 patients, and glutaraldehyde levels in the recycled rinse water of the endoscope washing machine were measured. The incidence of symptoms in the subsequent 612 patients after installation of a washer that does not recycle rinse water was examined. RESULTS: Five patients (1.3 per cent) presented to hospital with bloody diarrhoea occurring immediately after a normal flexible sigmoidoscopy. Repeat examination confirmed the presence of proctitis. Symptoms subsided rapidly with either no treatment or steroid enemas. Eight additional patients (2.1 per cent) recorded similar problems but received no treatment and the symptoms settled spontaneously. Glutaraldehyde levels rose progressively in the rinse water after each wash cycle with 2 per cent glutaraldehyde solution. Only one possible case of proctitis (0.2 per cent) was identified from the questionnaires completed by 612 patients after changing to a washer that did not recycle the rinse water. CONCLUSION: These observations should prompt the careful assessment of cleaning techniques. The use of washing machines that do not recycle rinse water may avoid this complication.

Fine-bore cannulas for peripheral intravenous nutrition: polyurethane or silicone?

The peripheral intravenous route is being used more frequently for the administration of short- to medium-term parenteral nutritional support. Dedicated fine bore cannulas have significantly reduced the incidence of thrombophlebitis. Currently available cannulas are made of polyurethane or silicone. We present our experience with a 23G silicone cannula and a 22G polyurethane alternative. Fifty-four silicone cannulas were used with a median survival of only 3 days, compared with 7 days for 90 polyurethane cannulas (P < 0.0001). Only 22% of silicone cannulas were removed electively compared with 56% of polyurethane cannulas (P < 0.00005). The most common cause for silicone cannula removal was occlusion (48%), which occurred in only 8% of polyurethane cannulas (P < 0.00001). Polyurethane cannulas develop fewer complications and are more effective in the delivery of peripheral intravenous nutritional support.

Rectal hypersensitivity in the irritable bowel syndrome.

Studies of rectal sensory thresholds and compliance in patients with the irritable bowel syndrome have produced conflicting results though there is persistent evidence of rectal hypersensitivity particularly in those with diarrhoea-predominant symptoms. This study examined rectal sensation and compliance in 31 patients with constipation-predominant irritable bowel syndrome (mean age 41 years, 27 female) and 17 healthy volunteers (mean age 45 years, 17 female). A rectal balloon was inflated with fluid at a constant rate and the volume and intrarectal pressure at sensory threshold was recorded. The volumes at first (129 +/- 8 vs 229 +/- 24 ml, P < 0.001 Mann-Whitney-U test), constant (159 +/- 12 vs 286 +/- 21, P < 0.001) and maximum tolerated sensation (290 +/- 13 vs 509 +/- 19, P < 0.001) were all significantly less in the irritable bowel group. There was no significant difference in intrarectal pressures at any of these volumes (29.0 +/- 2.2 cmH2O vs 29.0 +/- 2.5, 35.0 +/- 2.5 vs 34.0 +/- 2.8, 71 +/- 2.5 vs 65.0 +/- 3.0 respectively). Rectal compliance was significantly less in the irritable bowel group (3.6 +/- 0.2 ml/cmH2O vs 8.7 +/- 0.4, P < 0.001). Twenty two patients complained of abdominal pain on balloon inflation, mimicking that experienced as part of their symptoms. Patients with constipation-predominant irritable bowel syndrome have rectal hypersensitivity and reduced compliance.

Neutrophil adhesion molecule expression and response to stimulation with bacterial wall products in humans is unaffected by parenteral nutrition.

1. Total parenteral nutrition is associated with a high incidence of septic complications. This may be partly due to neutrophil dysfunction induced by the parenteral nutrition. 2. Neutrophil adhesion molecule expression and the expression of CD11b in response to stimulation with formylmethionyl-leucyl-phenylalanine and lipopolysaccharide were determined before and after 24 h of lipid-containing parenteral nutrition. Eighteen adult patients referred for parenteral nutrition were studied. 3. There was no change in the expression of neutrophil L-selectin (CD62L), CD11a, CD11b, CD11c or CD15. Neutrophil response to stimulation with formylmethionyl-leucyl-phenylalanine and lipopolysaccharide as determined by CD11b expression was unaffected by parenteral nutrition. 4. This study has shown no evidence of parenteral nutrition-induced neutrophil dysfunction.

Physiological changes after Delorme's procedure for full-thickness rectal prolapse.

Anal sphincter pressures, rectal compliance and sensation in 19 women of mean age 77 (range 57-94) years were studied before and after Delorme's procedure for full-thickness rectal prolapse. No patient had significant problems with defaecation after operation. There were no significant changes in anal sphincter pressures but the volume of first rectal sensation decreased from a median of 140 ml before surgery to 65 ml after the procedure (P = 0.01) and the maximum tolerated rectal volume declined from a median of 249 ml to 120 ml (P = 0.001). Rectal compliance was reduced from a median of 142.9 ml/kPa to 12.2 ml/kPa (P = 0.002). Improved rectal sensation and lowered compliance are associated with a reduced incidence of defaecatory problems after Delorme's procedure.

Prevention of postoperative renal dysfunction in patients with obstructive jaundice: a comparison of mannitol-induced diuresis and oral sodium taurocholate.

The effect of oral sodium taurocholate was compared with that of intravenous mannitol when used independently to determine their relative effect on protecting postoperative renal function in patients with obstructive jaundice. A total of 20 patients with obstructive jaundice were randomized to receive either mannitol or sodium taurocholate before surgery. Their preoperative and postoperative renal function was monitored using serum creatinine and predicted creatinine clearance over a 4-day period. There was no difference in postoperative renal function between the two groups and no patient from either group suffered significant renal dysfunction.