Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection.

OBJECTIVE: Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. METHOD: Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. RESULTS: Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively CONCLUSION: For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival.

Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin.

Several commonly prescribed antibiotics are known to interact with warfarin, increasing its anticoagulant effect by different mechanisms. Retroperitoneal bleeding with consequent haematoma is recognised as a complication of over-anticoagulation. Consequences, which are potentially fatal, include hypovolaemic shock and compression of retroperitoneal structures such as the ureter and inferior vena cava.

Multiple microaneurysms of the superior hemorrhoidal artery: unusual recurrent massive rectal bleeding: report of a case.

A case of massive rectal bleeding in a 38-year-old male patient from a previously unreported source is presented. Multiple microaneurysms affecting the rectum were demonstrated on an inferior mesenteric artery angiogram. The importance of angiography both for diagnosis and potential therapy in patients with continuous active lower gastrointestinal bleeding is emphasized.

Nitric oxide synthase neurones and neuromuscular behaviour of the anorectum.

Intensive research into the biological roles of nitric oxide has shown that this tiny molecule is of vital physiological significance in numerous organ systems including the gastrointestinal tract, where nitric oxide has been proposed as an inhibitory enteric neurotransmitter. This paper outlines experiments using retrograde neuronal tracing and enzyme histochemistry in a guinea-pig model which provided the first direct anatomical evidence of a descending nitrergic rectoanal neuronal pathway appropriate to mediating relaxation of the internal anal sphincter during the rectoanal inhibitory reflex. Studies of human tissue showed that the in vitro responses of isolated strips of human rectum were typical of non-sphincter specialized gastrointestinal smooth muscle, that nitric oxide is involved in neurogenic relaxation of the rectum and that nitric oxide synthase immunocytochemistry identified a subpopulation of neurones in the myenteric ganglia and immunoreactive profiles within both layers of the muscularis propria of human rectum. Taken together, these data provide pharmacological and anatomical support for the hypothesis that nitric oxide acts as a functionally important mediator in the innervation of human anorectum.

Outcome of 200 restorative proctocolectomy operations: the John Radcliffe Hospital experience.

BACKGROUND: Restorative proctocolectomy is now the operation of choice for the definitive management of ulcerative colitis and familial adenomatous polyposis (FAP). METHODS: A total of 200 patients (117 male, 83 female) underwent restorative proctocolectomy over a 12-year period. Information in a dedicated prospective database was supplemented by chart review. Some 177 had ulcerative colitis, 13 had indeterminate colitis and seven had FAP. Pouch designs were two-loop J (n = 142), four-loop W (n = 45) and three-loop S (n = 13). The majority (73.5 per cent) had a stapled ileoanal anastomosis and 139 patients had a defunctioning ileostomy. RESULTS: There were no deaths. Early morbidity (less than 30 days after operation) included 76 complications in 71 patients (35.5 per cent), of which 35 were related to the pouch itself. Long-term follow-up data were available for 196 patients at a median of 27 months. Sixteen pouches (8.0 per cent) have been excised. Mean daytime frequency was 4.5 (range 1-15). Of 175 patients with colitis, 42 (24.0 per cent) had one or more episodes of pouchitis. CONCLUSION: Continuous improvements in operative technique have simplified the procedure, and functional results, although variable, have generally been acceptable.

Role of nitric oxide in relaxation of the longitudinal layer of rectal smooth muscle.

PURPOSE: This study was designed to investigate the role of nitric oxide in neurogenic relaxation of the longitudinal layer of human rectal smooth muscle. METHODS: Tissue was obtained from the mid rectum of patients undergoing anterior resection for carcinoma. Adjacent strips of longitudinal muscle were dissected and mounted in organ baths for isometric tension recording. In preliminary experiments to determine the response of strips to cholinergic, adrenergic, and potential excitatory agonists, strips were superfused with standard Krebs solution (37 +/- 0.5 degrees C; pH, 7.4 +/- 0.05). Investigation of inhibitory, nonadrenergic noncholinergic responses required the addition of 3 x 10(-6) M histamine to induce reproducible and stable tension for five-minute "test" periods, during which electrical field stimulation (EFS) and additional drugs were applied. In these experiments, strips were superfused with Krebs solution that contained atropine sulfate (3 x 10(-6) M) and guanethidine (3 x 10(-6) M). RESULTS: The response to cholinergic and adrenergic agonists was typical of nonsphincter specialized gastrointestinal smooth muscle. EFS elicited frequency-dependent, neurogenic (tetrodotoxin-sensitive) relaxations of precontracted strips, which were reduced in dose-dependent fashion by addition of N omega-nitro-L-arginine and restored by addition of 3 x 10(-4) M L-arginine but not by D-arginine. Addition of exogenous nitric oxide (sodium nitroprusside) mimicked the relaxant response induced by EFS. CONCLUSION: Smooth muscle from the longitudinal layer of human rectum receives an intrinsic inhibitory innervation mediated by nitric oxide.

Restorative proctocolectomy in children and adolescents.

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.

Ambulatory manometric examination in patients with a colonic J pouch and in normal controls.

Anorectal function after anterior resection may be impaired as a result of reduced luminal capacity in the pelvis. The aim of this study was to evaluate the colonic J pouch neorectum by means of ambulatory manometry. Twelve patients with a colonic pouch following anterior resection and seven healthy controls were studied for a median of 6 (range 6-24) h using a probe with two pouch-rectal and two anal canal transducers. Records were interpreted by visual inspection. Pressure values and wave frequencies were determined by software analysis. Pouches had been functioning for a median of 32 (range 11-55) months. All patients with a pouch had an acceptable stool frequency. Seven of 12 patients complained of incomplete evacuation. Resting anal canal pressure (73 versus 100 cmH2O), pouch-rectal pressure (29 versus 15 cmH2O) and anal canal pouch-rectal pressure gradients (60 versus 85 cmH2O) were similar in patients and controls. The frequency of slow-wave activity in patients with a pouch was significantly lower than that in controls (7 versus 16 cycles per min, P = 0.001). Coordination between the colonic J pouch and the anal canal, in the form of sampling episodes, was observed in more than half of the patients with a functioning pouch. Large isolated contractions (pressure greater than 30 cmH2O and lasting longer than 20 s) and rhythmic contractions were the most frequent pattern of pouch motility.

Nitric oxide and the rectoanal inhibitory reflex: retrograde neuronal tracing reveals a descending nitrergic rectoanal pathway in a guinea-pig model.

Nitric oxide has been implicated as the neurotransmitter mediating internal anal sphincter (IAS) relaxation during the rectoanal inhibitory reflex. However, there has been no direct demonstration of a nitrergic rectoanal neuronal pathway appropriate to mediating the reflex. This study combined retrograde neuronal tracing techniques with enzyme histochemistry in a guinea-pig model. Wheatgerm agglutinin conjugated to horseradish peroxidase was injected into the IAS. Transported tracer was demonstrated in neurones of the myenteric ganglia of the distal rectum and all labelled neurones showed co-localization with nitric oxide synthase as revealed by reduced nicotinamide adenine dinucleotide phosphate diaphorase histochemistry. In vivo anal canal manometry showed that the mean maximal resting pressure was 16 (8-20) cmH2O and confirmed the presence of the rectoanal inhibitory reflex. In vitro organ bath studies showed that strips of IAS developed spontaneous myogenic tone and relaxed in response to intrinsic nerve stimulation. Addition of N omega-nitro-L-arginine (L-NOArg) reduced the relaxant response in a dose-dependent fashion; the relaxant response was maximally reduced by a mean(s.e.m.) 35.2(3.8) per cent (P < 0.001) at a concentration of 3 x 10(-5) mol/l L-NOArg. This study provides direct anatomical evidence of a descending nitrergic rectoanal neuronal pathway in a guinea-pig model. In vivo anal manometry and in vitro organ bath studies provide additional evidence that this pathway is responsible for the inhibitory motor innervation of the rectoanal inhibitory reflex.

Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease.

BACKGROUND: An increasing number of patients with severe or refractory ulcerative colitis involving only the rectum and sigmoid colon are being offered restorative proctocolectomy with ileal reservoir but very few data are available concerning the outcome for these patients. AIM: This study was designed to compare the outcome of ileal pouch procedures for distal ulcerative colitis with procedures performed for more extensive disease. PATIENTS: A consecutive series of 177 patients undergoing restorative proctocolectomy for ulcerative colitis between January 1984 and December 1994. METHODS: Data were collected prospectively in a dedicated ileal pouch database and included demographic details, indication for surgery, surgical procedures performed, early (< 30 days) and late morbidity, functional outcome, and histopathology. RESULTS: There was no mortality in the series. The incidence and range of early morbidity (< 30 days) and the functional outcome (daytime stool frequency, nocturnal frequency, and the incidence of incontinence) were similar for all groups. Log rank analysis of Kaplan-Meier estimates showed no significant difference between groups in the likelihood of developing pouchitis (p > 0.2). CONCLUSIONS: Patients undergoing restorative proctocolectomy for distal colitis experience a similar outcome to patients with more extensive disease. These data refute the hypothesis that pouchitis is more common in patients with total colitis.

Nitrergic innervation and relaxant response of rectal circular smooth muscle.

PURPOSE: This study was designed to investigate whether nitric oxide mediates inhibitory innervation in human rectal circular smooth muscle. METHODS: Tissue was obtained from the midrectum of patients undergoing anterior resection for carcinoma. Adjacent strips of circular muscle were dissected and mounted in superfusion organ baths for isometric tension recording and initially loaded with 1 g of weight. Strips were continuously bathed with standard Krebs solution (37 degrees C, bubbled with 97 percent O2/3 percent CO2) containing 3 X X 10(-6) M guanethidine and 3 X 10(-6) M atropine sulfate to block adrenergic and muscarinic cholinergic neurotransmission. After equilibration, strips had no intrinsic tone, and reproducible and stable tension was, therefore, induced by the addition of 3 X 10 M histamine for five-minute "test" periods, during which electrical field stimulation (EFS) and additional drugs were applied. RESULTS: EFS elicited frequency-dependent, neurogenic (tetrodotoxin-sensitive) relaxations of precontracted strips. Addition of N-w-nitro-L-arginine, a powerful competitive inhibitor of nitric oxide synthase, reduced the relaxant response to EFS in a dose-dependent fashion, and effect reversed by addition of s X 10(-4) M L-arginine but not by D-arginine. Addition of exogenous nitric oxide (sodium nitroprusside) mimicked the relaxant response induced by EFT. CONCLUSIONS: Human rectal circular smooth muscle receives an intrinsic inhibitory innervation mediated by nitric oxide. The presennce of a residual response following blockade of the enzyme nitric oxide synthase suggests the involvement of additional neurotransmitters.

Recurrence and reoperation after strictureplasty for obstructive Crohn's disease: long-term results [corrected].

Strictureplasty extends the surgical options for the treatment of obstructive Crohn's disease. Over 15 years, 52 patients had 241 strictureplasties at 76 operations with no operative mortality and with septic complications in only two patients (4 percent). Median (range) follow-up was 49.5 (1-182) months. Nineteen patients (36 percent) required a second operation for Crohn's disease between 1 and 57 months after first strictureplasty. Most symptomatic recurrence was caused by new segments of stricturing or perforating disease, and recurrence of Crohn's disease was noted at only nine strictureplasty sites (3.7 percent) in four patients. Seven patients (13 percent) required a third operation for Crohn's disease. Patients undergoing strictureplasty alone were no more likely to require reoperation than those who had a concomitant resection at the first procedure (X2 = 0.619, P > 0.2). The reoperation rates after first and second operations were similar (X2 = 0.021, P > 0.2). Minimal surgery does not appear to lead to an accelerated or additional need for subsequent operation. Strictureplasty provides a safe, effective and rapid procedure to restore patients to good health while preserving the intestine and may be recommended for carefully selected strictures as an adjunct to conventional excisional surgical treatment.

Nitrergic inhibitory innervation of porcine rectal circular smooth muscle.

This study was performed to determine whether nitric oxide contributes to inhibitory non-adrenergic non-cholinergic (NANC) neurotransmission in the circular smooth muscle layer of pig rectum. Smooth muscle strips were mounted for isometric tension recording in superfusion organ baths. In the presence of atropine sulphate and guanethidine, transmural electrical field stimulation (EFS) produced frequency-dependent relaxation of precontracted muscle strips. N omega-nitro-L-arginine (L-NOArg), a powerful competitive antagonist of nitric oxide synthase, reduced the relaxant response in dose-dependent fashion; this response was maximally reduced by mean(s.e.m.) 86.5(2.6) per cent (P = 0.0003) at a concentration of 3 x 10(-5) mol/l L-NOArg. The response was restored by the addition of L-arginine. Sodium nitroprusside, an exogenous donor of nitric oxide, mimicked the relaxant response. Responses to EFS were abolished by tetrodotoxin. These results suggest that inhibitory NANC neurotransmission in this tissue is mediated, at least in part, by nitric oxide. The failure of L-NOArg to completely abolish the relaxant response suggests that additional neurotransmitters may be involved.

Diagnosis and management of phyllodes tumour of the breast: experience of 33 cases at a specialist centre.

This study reviews the diagnosis and management of a consecutive series of 33 phyllodes tumours of the breast treated at The Royal Marsden Hospital, Sutton, between 1981 and 1992. The mean age of patients at presentation was 41 years (range 15-67 years). Tumours occurred equally in each breast and were significantly more common in the upper outer quadrant (chi 2 = 12.7, df = 3, P < 0.01). Clinical features (age, tumour size, palpation) and diagnostic investigations (mammography, ultrasound and fine needle aspiration cytology) were not sufficiently accurate to reliably make a preoperative diagnosis or predict histological type (benign, borderline or malignant). The diagnosis of phyllodes should be considered in patients aged 30-50 years with an apparent fibroadenoma. Of the patients, 66% underwent wide excision or mastectomy resulting in a favourable local recurrence rate of 14%. Our experience and review of the literature suggests that adequate local surgery is the treatment of choice and adjuvant treatments have no place in the routine management of phyllodes tumours. Regional lymph nodes were not involved in any of our patients and axillary dissection is not indicated.

Avoidable delay in the management of carcinoma of the right colon.

A retrospective study of 89 consecutive patients with carcinoma of the right colon presenting in a district general hospital over a 5-year period is reported. Of the patients, 74% were anaemic at the time of diagnosis and 27% of these had anaemia or a low mean corpuscular volume (MCV) for a significant time (mean 177 days, range 76-496 days) before developing symptoms. All doctors should be more vigilant towards anaemia or low MCV as presymptomatic indicators of possible colonic disease. Appropriate investigation is required in order to detect disease at an earlier stage and therefore influence survival. Significant delay in the diagnosis of symptomatic disease occurs before referral to hospital (mean 61 days vs 36 days, P < 0.05). Treatment delay is similar whether patients are referred to surgeons or physicians. The preoperative duration of symptoms for emergency admissions was significantly shorter than for elective admissions (mean 50 days vs 119 days, P < 0.05). The 30-day mortality was significantly higher for emergency admissions (20.7% vs 3.3%, P < 0.05). Earlier diagnosis of symptomatic disease may not reduce the proportion of emergency admissions (33%) or improve survival. Many tumours are at an advanced pathological stage (39% node positive) by the time symptoms develop.

Noncalculous obstruction due to involvement of the ureter in endometriosis.

A retrospective case series of 5 consecutive patients presenting with endometriosis of the ureter between 1978 and 1992 is reported. All patients were managed by a single Consultant Urologist in a district general hospital. The mean age of patients was 40.4 years (34-45). Only 1 patient had symptomatic ureteric obstruction. In 4 patients the diagnosis was incidental. Preservation or salvage of renal function will usually require surgical intervention. The diagnosis should be considered in women presenting with noncalculous ureteric obstruction, particularly premenopausal women of low parity or those who have had previously pelvic surgery. The pathology, presentation, investigation and management of the condition is discussed.