Endoscopic transanal resection of rectal adenomas using the urological resectoscope.

OBJECTIVE: Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital. METHOD: Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed. RESULTS: Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections. CONCLUSION: ETAR is simple and safe for managing rectal adenomas.

Endoscopic alternatives in managing anastomotic strictures of the colon and rectum.

BACKGROUND: The development of anastomotic strictures following colorectal surgery is a frequent problem, but commonly used treatments (e.g. dilatation or revisional surgery) are often ineffective. This study assessed the efficacy of self-expanding metallic stents (SEMS) and endoscopic transanal resection of strictures (ETARS) in managing high-grade benign colorectal anastomotic strictures after the failure of first-line therapies. METHODS: All patients with biopsy-proven benign anastomotic strictures (luminal diameter<7 mm) following colorectal surgery, seen in the period April 1995-October 2004, were treated with either SEMS or ETARS. RESULTS: In the study period, we treated 10 patients (7 men) of median age 71 years. Ten ETARS procedures were performed in six patients, with a mean operating time of 42 minutes and a median hospital stay of 1 day. Early complications of ETARS included: re- operation for bleeding, asymptomatic anastomotic perforation and technical failure in an acutely angulated stricture. SEMS were successfully inserted into five patients (including two with failed ETARS) without any early complications. Overall, nine patients have had satisfactory longterm outcomes (median follow-up, 29 months; range, 3-75 months). CONCLUSIONS: SEMS and ETARS are simple, safe and effective methods in treating high-grade anastomotic strictures.

Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes.

OBJECTIVE: The use of stents for benign colorectal obstruction is considered controversial because of a lack of data and perceived high failure and complication rates. The aim of this study was to evaluate the indications and outcomes following stent placement for benign colorectal disease in a UK district general hospital and to review the published literature. PATIENTS AND METHODS: Between 1997 and 2004, 11 of 90 attempted stent insertions were performed for benign colorectal disease (diverticular disease, 4; anastomotic strictures, 4; idiopathic rectal stricture, 1; rectal endometriosis, 1; caecal volvulus, 1). Complications and outcomes were analysed from a prospective database. RESULTS: Stent insertion was successful in nine patients. Early complications occurred in two patients (both with diverticular disease): one patient failed to decompress and needed a colostomy and laparotomy was performed in a second patient who developed peritonitis after five days although no stent perforation of the bowel was identified. Two patients were successfully decompressed and underwent subsequent elective surgery with full bowel preparation. Stent placement resulted in symptomatic improvement in three out of four patients with anastomotic strictures (allowing closure of defunctioning stomas) and in the one patient with an idiopathic rectal stricture. Stent migration occurred in two of these patients without recurrence of symptoms. Stent fracture occurred in one patient, who remained symptomatic. CONCLUSIONS: Self-expanding metallic stents are an effective treatment for benign colorectal obstructions, especially anastomotic strictures with long-term patency. Stents should be avoided in acute diverticular disease because of a higher incidence of complications.

Colovesical fistula--is a surgical approach always justified?

OBJECTIVE: There is a tendency to over investigate patients with colovesical fistula and to advise surgical intervention as the sole course of action. Most patients are elderly and operative intervention often carries a high morbidity and mortality. PATIENTS AND METHODS: A retrospective study of 50 patients diagnosed with a colovesical fistula over a 12-year period was undertaken at our institution. The notes of all these patients were reviewed using a standardized proforma to look at the referral pattern, symtomatology, investigation, treatment and outcomes. RESULTS: Data analysis showed the median age of these patients to be 70 years with 92% having either pneumaturia or faecaluria or both as a symptom. There was no significant difference in disease-specific mortality in patients with benign colovesical fistula undergoing surgical intervention and patients treated conservatively. There was not a single documented case of septicaemia despite untreated colovesical fistula being present for a cumulative total of 3254 weeks. There was no statistically significant decline in the renal function due to the disease. CONCLUSION: We suggest that fewer investigations be performed for the diagnosis of colovesical fistula and conservative management offered to patients with benign pathology.