Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study.

PURPOSE: There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre. MATERIALS AND METHODS: A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017. RESULTS: The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required. CONCLUSION: Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.

Quality of life following fistulotomy - short term follow-up.

AIM: Anal fistula causes pain and discharge of pus and blood. Treatment by fistulotomy has the highest success, but can risk continence; treatment needs to balance cure with continence. This study assessed the impact of fistulotomy on quality of life (QOL) and continence. METHOD: Patients selected for fistulotomy prospectively completed the St Mark's Continence Score (full incontinence = 24) and Short Form-36 questionnaires preoperatively at two institutions with an interest in anal fistula. Patients were reassessed 3 months' postoperatively. RESULTS: There were 52 patients with a median age of 44 (range 19-82) years; 10 were women. Preoperative continence scores were median 0 (range 0-23) and there was no significant difference compared with postoperative scores (median 1, range 0-24). Following fistulotomy QOL was significantly improved in four of eight domains - Bodily Pain (P < 0.001), Vitality (P < 0.01), Social Functioning (P < 0.05) and Mental Health (P < 0.001) - and returned to that of the general population. QOL for patients with intersphincteric fistula improved postfistulotomy, and for those with trans-sphincteric fistula it remained the same. Data were further examined in two groups, with and without deterioration in continence score. Where continence improved postoperatively, QOL improved in three domains; where continence deteriorated QOL improved in two domains (P < 0.05). Patients with postoperative continence scores of < 5 had worse QOL than those scoring 4 or less. CONCLUSION: QOL significantly improved at 3 months' follow-up after fistulotomy where continence was maintained or a small reduction occurred.

Integrated total pelvic floor ultrasound in pelvic floor defaecatory dysfunction.

AIM: Imaging for pelvic floor defaecatory dysfunction includes defaecation proctography. Integrated total pelvic floor ultrasound (transvaginal, transperineal, endoanal) may be an alternative. This study assesses ultrasound accuracy for the detection of rectocele, intussusception, enterocele and dyssynergy compared with defaecation proctography, and determines if ultrasound can predict symptoms and findings on proctography. Treatment is examined. METHOD: Images of 323 women who underwent integrated total pelvic floor ultrasound and defaecation proctography between 2011 and 2014 were blindly reviewed. The size and grade of rectocele, enterocele, intussusception and dyssynergy were noted on both, using proctography as the gold standard. Barium trapping in a rectocele or a functionally significant enterocele was noted on proctography. Demographics and Obstructive Defaecation Symptom scores were collated. RESULTS: The positive predictive value of ultrasound was 73% for rectocele, 79% for intussusception and 91% for enterocele. The negative predictive value for dyssynergy was 99%. Agreement was moderate for rectocele and intussusception, good for enterocele and fair for dyssynergy. The majority of rectoceles that required surgery (59/61) and caused barium trapping (85/89) were detected on ultrasound. A rectocele seen on both transvaginal and transperineal scanning was more likely to require surgery than if seen with only one mode (P = 0.0001). If there was intussusception on ultrasound the patient was more likely to have surgery (P = 0.03). An enterocele visualized on ultrasound was likely to be functionally significant on proctography (P = 0.02). There was, however, no association between findings on imaging and symptoms. CONCLUSION: Integrated total pelvic floor ultrasound provides a useful screening tool for women with defaecatory dysfunction such that defaecatory imaging can avoided in some.

Quality of life with anal fistula.

INTRODUCTION: Anal fistula affects people of working age. Symptoms include abscess, pain, discharge of pus and blood. Treatment of this benign disease can affect faecal continence, which may, in turn, impair quality of life (QOL). We assessed the QOL of patients with cryptoglandular anal fistula. METHODS: Newly referred patients with anal fistula completed the St Mark's Incontinence Score, which ranges from 0 (perfect continence) to 24 (totally incontinent), and Short form 36 (SF-36) questionnaire at two institutions with an interest in anal fistula. The data were examined to identify factors affecting QOL. RESULTS: Data were available for 146 patients (47 women), with a median age of 44 years (range 18-82 years) and a median continence score of 0 (range 0-23). Versus population norms, patients had an overall reduction in QOL. While those with recurrent disease had no difference on continence scores, QOL was worse on two of eight SF-36 domains (p<0.05). Patients with secondary extensions had reduced QOL in two domains (p<0.05), while urgency was associated with reduced QOL on five domains (p<0.05). Patients with loose seton had the same QOL as those without seton. No difference in urgency was found between patients with and without loose seton. In primary fistula patients, 19.4% of patients experienced urgency versus 36.3% of those with recurrent fistulas. CONCLUSIONS: Patients with anal fistula had a reduced QOL, which was worse in those with recurrent disease, secondary extensions and urgency. Loose seton had no impact on QOL.

Synchronized functional anal sphincter assessment: maximizing the potential of anal vector manometry and 3-D anal endosonography.

BACKGROUND: Understanding the association between structure and function is vital before considering surgery involving anal sphincter division. By correlating three-dimensional anal endosonography (AES) and three-dimensional anal canal vector volume manometry (VVM), this study details a method to produce measurements of both sphincter length and pressure leading to identification of the functionally important areas of the anal canal. The aim of this study was to provide combined detailed information on anal canal anatomy and physiology. METHODS: Twelve males and 12 nulliparous females with no bowel symptoms underwent VVM (using a water-perfused, eight-channel radially arranged catheter) and AES. KEY RESULTS: The synchronization of AES and VVM identified that the majority of rest and squeeze anal pressure is present in the portion of the anal canal covered by both anal sphincters. Nearly, 20% of overall resting anal pressure is produced distal to the caudal termination of the internal anal sphincter. Puborectalis accounts for a significantly greater percentage volume of pressure in females both at rest and when squeezing, though the total volume of pressure is not significantly greater. CONCLUSIONS AND INFERENCES: The majority of resting and squeezing pressure and the least asymmetry, in both sexes, is in the portion of the anal canal covered by external anal sphincter. In females, the external anal sphincter is shorter and a proportionately longer puborectalis accounts for a greater percentage of pressure. Sphincter targeted fistula surgery in females must be performed with special caution. A protective role for puborectalis following obstetric anal sphincter injury is suggested.

The future of pelvic floor services in the UK.

AIM: The study aimed to determine the current state of UK pelvic floor services and to discuss future strategies. METHOD: A questionnaire developed by the Pelvic Floor Society was sent in 2014 to the 175 colorectal units recognized by the Association of Coloproctology of Great Britain and Ireland. Questions included type of centre, frequency of pelvic floor clinics/interdisciplinary joint pelvic floor clinics/multidisciplinary meetings (MDMs) and workload. RESULTS: Sixty-seven (38%) centres replied including 75% of units with a consultant who was as member of the Pelvic Floor Society. Of the 67 centres 39% were tertiary centres for pelvic floor surgery (tertiary), 48% performed some pelvic floor surgery (regional) and 13% did not perform any (local). Ninety-six per cent of tertiary referral centres served a population over 500 000. The mean number of whole time equivalent consultants in tertiary centres was 1.03 and 0.77 in regional centres. Eighty per cent of tertiary centres and 56% of regional centres ran pelvic floor clinics. Eighty-four per cent of tertiary referral and 75% of regional units held or attended an MDM. Anal ultrasonography, anorectal physiology and proctography were performed in 96% of tertiary centres compared with 50% of non-tertiary units. CONCLUSION: The provision of pelvic floor services includes local, regional and tertiary centres. The overall response rate was low (38%) and biased to centres with a consultant who was a member of the Pelvic Floor Society. Not all regional or tertiary centres held an MDM or a pelvic floor clinic. Given the nature of pelvic floor pathology an integrated service should be aimed at linking different centres and specialities.

Initial experience of treating anal fistula with the Surgisis anal fistula plug.

BACKGROUND: Complex anal fistulas remain a challenge for the colorectal surgeon. The anal fistula plug has been developed as a simple treatment for fistula-in-ano. We present and evaluate our experience with the Surgisis anal fistula plug from two centres. METHODS: Data were prospectively collected and analysed from consecutive patients undergoing insertion of a fistula plug between January 2007 and October 2009. Fistula plugs were inserted according to a standard protocol. Data collected included patient demographics, fistula characteristics and postoperative outcome. RESULTS: Forty-four patients underwent insertion of 62 plugs (27 males, mean age 45.6 years), 25 of whom had prior fistula surgery. Mean follow-up was 10.5 months Twenty-two patients (50%) had successful healing following the insertion of plug with an overall success rate of 23 out of 62 plugs inserted (35%). Nineteen out of 29 patients healed following first-time plug placement, whereas repeated plug placement was successful in 3 out of 15 patients (20%; p = 0.0097). There was a statistically significant difference in the healing rate between patients who had one or less operations prior to plug insertion (i.e. simple fistulas) compared with patients who needed multiple operations (18 out of 24 patients vs. 4 out of 20 patients; p = 0.0007). CONCLUSIONS: Success of treatment with the Surgisis anal fistula plug relies on the eradication of sepsis prior to plug placement. Plugs inserted into simple tracts have a higher success rate, and recurrent insertion of plugs following previous plug failure is less likely to be successful. We suggest the fistula plug should remain a first-line treatment for primary surgery and simple tracts.

Vector volume manometry--methods and normal values.

BACKGROUND: Vector volume manometry (VVM) can be used to assess patients with fecal incontinence. The VVM may be performed using a station pull through, or an automated technique. Currently no standard technique or equipment exists to assess anal canal VVM. This study aimed to assess the different techniques to produce repeatable results, and generate normal values for the vector volume profile. METHODS: Anal canal VVM was performed using a water-perfused system on 12 male and 12 nulliparous female volunteers. Manometry was performed with an automated puller withdrawn at 3 and 25mms(-1) using a station technique. The VVM profiles were calculated using 4, 8, and 16 channels. KEY RESULTS: The greatest repeatability of vector volume profile was seen with faster puller speed (25mms(-1) ) and with an 8-channel catheter. Men had higher squeeze volumes, maximal squeeze pressure, average squeeze pressure, and squeeze high pressure zone length. Women had a significantly greater anal canal asymmetry on both station and automated pull through at rest and when squeezing. Squeeze vector volume of pressure, mean maximum squeeze pressure, and the average squeeze pressure were significantly higher when calculated using the station technique. CONCLUSIONS & INFERENCES: The faster puller speed has improved agreement between vector profiles, which is most marked during active contraction. The 8-channel catheters have the greatest agreement between profiles. There is variation in values between automated manometry and the stationary pull through technique. The improved repeatability in automated VVM for healthy controls should improve its diagnostic utility in patients with incontinence.

Can haematological indices predict positive findings at endoscopy in anaemic patients?

INTRODUCTION: Patients with anaemia are commonly referred for bidirectional endoscopy. The aim of this study was to determine if any haematological parameters could predict positive findings at endoscopy. PATIENTS AND METHODS: A total of 209 patients had bidirectional endoscopies performed for anaemia between September 2002 and March 2004. The endoscopy reports, histology and full blood count results (haemoglobin [Hb], red blood cells [RBCs], packed cell volume [PCV], mean cell volume [MCV] and mean cell haemoglobin [MCH]) were then reviewed. Statistical analysis was performed using non-parametric tests. RESULTS: Overall, 197 patients had successful bidirectional endoscopies with 12 requiring completion barium enema. In 48 (23%) of these patients, a cause of anaemia was found with 15 (7.2%) carcinomas detected (2 upper GI and 13 lower GI). There was a significant difference in haemoglobin (9.2 g/dl versus 10.1 g/dl; P = 0.0044), RBCs (3.56 x 10(12)/l versus 3.83 x 10(12)/l; P = 0.0325) and PCV (0.279 l/l versus 0.31 l/l; P = 0.0112) between patients with positive findings at endoscopy and those with a normal investigation. Cancer patients had significantly lower haemoglobin (8.65 g/dl versus 10.1 g/dl; P = 0.0103), RBCs (3.45 x 10(12)/l versus 3.83 x 10(12)/l; P = 0.0179) and PCV (0.27 l/l versus 0.31 l/l; P = 0.0298) compared with patients with normal endoscopies. There was no significant difference in the other haematological parameters between those found to have positive findings and those that had normal endoscopies. CONCLUSIONS: Based on this study, the yield of bidirectional endoscopy is low, with haemoglobin and PCV being the most useful haematological indices of significant pathology. Ferritin and MCV did not predict the likelihood of finding a gastrointestinal cause for the anaemia.

Digestive tract schwannoma.

BACKGROUND: Digestive tract schwannomas (DTS) are rare benign mesenchymal tumours usually affecting females between 30 and 60 years old. METHODS: We retrospectively reviewed 2 cases of DTS treated at our hospital. The first case is a 38-year-old female with gastric schwannoma presenting with acute upper gastro-intestinal bleeding. The second case is a 36-year-old female with mesenteric schwannoma presenting with chronic right iliac fossa pain. Both patients underwent surgical resection of the tumour. RESULTS: Histology and immunohistochemistry revealed the typical appearance of a DTS. CONCLUSION: DTS is most commonly found in the stomach. It is usually asymptomatic but can present with variable symptoms. Definitive diagnosis can only be made on the basis of immunohistochemistry. Surgical resection is the treatment of choice.