[show abstract][hide abstract] ABSTRACT: The efficacy of rectal irrigation (RI) was assessed in patients with various functional bowel disorders.
A prospective analysis was carried out of patients presenting to our functional bowel clinic from 2005 to 2009. The Cleveland Clinic Constipation and Incontinence Scores were used to assess outcomes following rectal irrigation. Patients were asked if they were satisfied with RI and would recommend it to a friend.
Ninety-one patients (80 female, median age 51 (17-78) years had undergone rectal irrigation for the following indications: chronic constipation (n = 32), slow transit constipation (n = 18), obstructed defaecation (n = 10), and faecal incontinence (n = 31). Of the 60 patients with constipation, 50 (83%) were available for follow up. Mean constipation scores improved from 18.72 to 11.45 following rectal irrigation (P = 0.001). Twenty-five patients experienced failure of RI to control symptoms, 10 of whom were offered surgery. Of the patients with incontinence, 20 (67%) were available for follow up. Mean incontinence scores improved from 16.2 to 10.8 with rectal irrigation (P = 0.005). Twelve patients discontinued RI, the commonest reason being lack of improvement in symptoms. Seven of these patients were offered surgery. The only complication was in one patient with constipation who had minor rectal bleeding following irrigation, which was stopped.
Rectal irrigation can be a useful tool in the management of functional bowel disorders and should be tried prior to the consideration of any surgery. However, further work is needed to define the precise indications and patient selection criteria.
[show abstract][hide abstract] ABSTRACT: Laparoscopic colorectal surgery includes operative procedures of varying complexity, and traditional assessment tools may not be enough to assess competence. This study defines quantitative tools for assessing proficiency in laparoscopic colorectal surgery.
A single surgeon's 11-year experience was subdivided into five phases with equal numbers of patients. A tool-kit, with specific tools defined as the complexity score, the conversion score, the technical score, the training score and the proficiency score, has been developed and used to evaluate each phase of the experience.
There were 400 patients, with 80 in each of the five phases. The complexity score increased from 23.75 to 63.75 over the five phases. Similar increases were also demonstrable in the conversion score (from 0.45 to 15.45), the technical score (from 30 to 96.5), the training score (from 5.8 to 34.8) and the overall proficiency score (from 15 to 52.63).
The results show that it is possible to quantify the workload in laparoscopic colorectal surgery and to assess increasing proficiency using a simple, reproducible and reliable tool-kit.
[show abstract][hide abstract] ABSTRACT: Laparoscopic colorectal surgery has become more common with the increase in the number of trained surgeons. We have used a disposable uterine manipulator to retract the uterus. This technique has been found to be very useful for laparoscopic low anterior resection and abdomino-perineal resection in females.
Journal of Minimal Access Surgery 10/2010; 6(4):125.
[show abstract][hide abstract] ABSTRACT: Laparoscopic colorectal surgery includes a range of operations with differing technical difficulty, and traditional parameters, such as conversion and complication rates, may not be sensitive enough to assess the complexity of these procedures. This study aims to define a reproducible and reliable tool for quantifying the total workload and the complexity of the case mix.
This is a review of a single surgeon's 10-year experience. The intermediate equivalent value scoring system was used to code complexity of cases. To assess changes in the workload and case mix, the period has been divided into five phases.
Three hundred and forty-nine laparoscopic operations were performed, of which there were 264 (75.6%) resections. The overall conversion rate was 17.8%, with progressive improvement over the phases. Complex major operation (CMO), as defined in the British United Provident Association (BUPA) schedule of procedures, accounted for 35% of the workload. In spite of similar numbers of cases in each phase, there was a steady increase in the workload score, correlating with the increasing complexity of the case mix. There was no significant difference in the conversion and complications rates between CMO and non-CMO. The paradoxical increase in the mean operating time with increasing experience corresponded to the progressive increase in the workload score, reflecting the increasing complexity of the case mix.
This article establishes a reliable and reproducible tool for quantifying the total laparoscopic colorectal workload of an individual surgeon or of an entire department, while at the same time providing a measure of the complexity of the case mix.
[show abstract][hide abstract] ABSTRACT: This paper is a review of experience of laparoscopic colorectal surgery at a district general hospital with particular emphasis on the learning curve and training implications.
All patients undergoing colorectal surgery where laparoscopy was attempted between March 1998 and October 2003 were included in this study.
There were 80 patients of which 49 had malignancy. Twenty eight stomas and 52 bowel resections were performed laparoscopically. The conversion rate for bowel resection was 32% (decreasing from 38% to 44% to 22%). This was significant (p = 0.001) when compared with stoma formation (7%). The firm has support from a specialist registrar and staff grade surgeon. In 22% of cases, one of the middle grades was the principal operating surgeon, mainly laparoscopic mobilisation and stoma formation. Only 6% of resections were performed by the middle grades. Conversely, a middle grade was the main operating surgeon in 66% of open resections and 61% of stoma formations during the same period. There were in all two deaths and 14 postoperative complications. All patients who had laparoscopic resections for malignancy had clear resection margins.
This audit highlights that there is a long learning curve in laparoscopic colorectal surgery with decrease in conversion rates with increasing experience. There is also a reduction in training opportunities in open surgery during the learning phase of the consultant, although this may be counterbalanced by the exposure to laparoscopic techniques. Laparoscopic colonic mobilisation, as a part of stoma formation, is a good starting point for specialist registrar training.
Postgraduate medical journal 09/2005; 81(958):537-40. · 1.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: Splenic injury following colonoscopy is rare, with only 28 cases reported so far in the English language literature. Direct trauma during colonoscopy or traction on the spleno-colic ligament is the proposed mechanism of injury. Computed tomography (CT) of the abdomen is usually considered to be the most sensitive and specific modality for diagnosis. We report a case of a 56-year-old female, who was diagnosed having a splenic rupture following a routine colonoscopy for investigation of anaemia. She underwent an emergency laparotomy with splenectomy and made a satisfactory recovery post-operatively. We wish to highlight that there should be a high index of suspicion of splenic rupture in patients presenting with abdominal pain and demonstrating a positive Kehr's sign following colonoscopy. Only two case reports from the United Kingdom have been published, raising the possibility of under-reporting of such cases.
The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 09/2005; 3(4):293-5. · 1.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: We aimed to gather information from the members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to assess trends in the current practice of laparoscopic colorectal surgery.
A postal questionnaire survey of the members of ACPGBI.
The response rate was 37% (200/540). Only 45 surgeons currently perform laparoscopic colorectal work in Great Britain and Ireland mainly right hemicolectomy and laparoscopic stoma formation, of these about one third practiced laparoscopy for benign colorectal conditions only. The majority (68%) of surgeons had enough resources at their place of work, but further training seemed to be a major issue. Nearly 22% of surgeons had not had any formal training. Only 50% of surgeons trained their specialist registrars. The incidence of conversion rate was not different for benign or malignant conditions and also did not appear to be related to the duration of experience. Only four surgeons had noted port a site recurrence during the past 10 years. Seventy-five percent (150/200) felt that laparoscopic colorectal work could be carried out safely in a District General Hospital.
Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.
[show abstract][hide abstract] ABSTRACT: Fluid and electrolyte disorders are common in hospital patients and can cause serious complications, especially in the elderly. The task of fluid management is often left to the most junior members of the team, the senior house officer and the preregistration house officer. However, the level of teaching and support available to them in this regard appears to be unsatisfactory.
[show abstract][hide abstract] ABSTRACT: INTRODUCTION: Biopsies of colonic lesions are often reported as showing dysplasia, though in reality some lesions may harbour invasive malignancy. AIM: To assess the risk of underlying invasive malignancy in sessile polyps where biopsies had shown severe dysplasia and also to attempt to define a management strategy in such patients. METHODS: Between 1997 and 2001, 30 patients were diagnosed as having severe dysplasia using Morson's criteria in colonic lesions not amenable for endoscopic polypectomy. Severely dysplastic lesions were completely excised by appropriate surgical measures. RESULTS: Out of 30 patients, 15 had invasive cancers. Surgical intervention involved anterior resections, endoanal excisions, sigmoid colectomies, or abdomino-perineal excisions as deemed appropriate. The lesions ranged in size from 0.5 cm to 13 cm (mean 3.4 cm). There were nine T1 lesions (one of which was T1N1) and two each of T2, T3, T4 lesions (10 Dukes' A, 3 Dukes' B, 2 Dukes' C). Complete resection was confirmed histologically in all cases. One patient had a leak following endoanal excision, which required intervention. There was no mortality. DISCUSSION: This study demonstrates that endoscopic sampling can be misleading and severely dysplastic sessile lesions should be managed along the same principles as followed for invasive cancers, rather than adopting a 'wait and watch' policy with repeated endoscopies, biopsies or piece-meal polypectomies.
[show abstract][hide abstract] ABSTRACT: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease.
To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications.
A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients.
A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications.
Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.
Journal of the Royal College of Surgeons of Edinburgh 05/2002; 47(2):481-2, 484.
[show abstract][hide abstract] ABSTRACT: INTRODUCTION: Fast Track Colorectal Clinics are becoming a requirement to meet the government's 10-day rule for patients with suspected cancers to be seen by a specialist. However, such clinics soon tend to get overwhelmed by huge numbers of referrals, many of them inappropriate. The Association of Coloproctology of Great Britain and Ireland has published criteria for appropriate referral. We evaluated the sensitivity of these criteria and attempted to recommend appropriate changes. METHODS: Data of 50 consecutive colorectal cancers from our DGH since January 2000 has been collected in relation to demographics, presenting signs and symptoms, haemoglobin levels as well as treatment. The new Criteria were then applied strictly to these cases and we evaluated whether these patients would have been eligible for fast track referral, if these criteria had been in force since January 2000. RESULTS: Forty-one (82%) of 50 patients would have been eligible for referral as follows: 11 (22%) rectal bleeding with diarrhoea; 8(16%) persistent diarrhoea without bleeding (>60 years), 12 (24%) bleeding without anal symptoms (>60 years), 0 (0%) palpable right sided abdominal mass, 7 (14%) palpable rectal mass, 16 (32%) iron deficiency anaemia (<11 g/dl in men & <10 g/dl in women), 10 (20%) patients qualifying on more than one criterion. However, 9 (18%) patients had presenting features that would have excluded them from a fast track referral as follows: 4 (8%) only abdominal pain + weight loss (48, 54, 72, 75 years old), 2 (4%) change in bowel habit + no rectal bleeding (54, 57 years old), 1 (2%) palpable mass at a site other than the right side of the abdomen. CONCLUSIONS: We feel that this study, although small, highlights the dangers of having very rigid criteria for such clinics. The new criteria though high in specificity have low sensitivity for safety. We recommend some modifications to the criteria as follows: rectal bleeding without anal symptoms >50 years instead of 60 years; patients with a palpable mass anywhere on the abdomen; and the adddition of a new criterion of abdominal pain with weight loss. These modifications would significantly increase the sensitivity from 82% to 94%.
[show abstract][hide abstract] ABSTRACT: To audit all aspects of the diagnosis and management of colorectal cancers by a specialist unit within a District General Hospital (DGH). To compare the clinical effectiveness of the specialist service with the service prior to specialization and attempt to assess the feasibility of setting up such a service within the constraints imposed by a DGH.
Data for this study was collected prospectively over a 3-year period from July 1997 to June 2000 since the establishment of a specialist colorectal service. The results so obtained have been compared with the Trent and Wales audit of 1993 as well as with the guidelines issued by the Royal College of Surgeons of England and the Association of Colo-proctologists of Great Britain and Ireland. We have attempted to evaluate whether specialization has altered the outcome for patients with colorectal cancer.
A total of 2181 patients were seen at the specialist colorectal clinic and 42% underwent immediate flexible sigmoidoscopy. A total of 241 colorectal cancers were diagnosed during this period by the specialist unit, of which the rapid access clinic had picked up 191 (a pick-up rate of 8.75%). The mean age of patients with colorectal cancer was 69.23 years and the median waiting time from referral to clinic and from referral to treatment was 9 days and 24 days, respectively. These compare favourably with the waiting times prior to specialization. 117 rectal cancers were diagnosed of whom 32 (32%) underwent APER. A selective approach to short course preoperative radiotherapy resulted in 24% of rectal cancer patients receiving this treatment. The CRM was positive in 14% of resected rectal cancers, all of whom had received preoperative radiotherapy. The percentage of patients with Dukes' stage A disease has risen from 11% in 1993 to 23% and the percentage of patients undergoing emergency surgery have fallen from 29% in 1993 to 8.2%. The rate of permanent stoma formation has also decreased from 52% to 32%. This audit has also confirmed that the guidelines for the management of colorectal cancers were all being met or exceeded.
The study demonstrates that, even within the constraints of a DGH, a specialist service can result in earlier diagnosis, shorter waiting periods and judicious use of adjuvant treatment leading to improved clinical effectiveness. It is possible to deliver a high quality service, which meets, and in some areas, surpasses the minimum guidelines, provided there is an integrated multidisciplinary approach.