Neil Mortensen

• MB ChB, MA, MD, FRCS Eng, hon FRCS Glas, hon FRCS Edin, hon FRCSI
• Consultant at University of Oxford

Why we will need senior surgeons spending longer in the profession.

Aim: Pouch-vaginal fistula (PVF) is an uncommon but serious complication of ileo-anal pouch reconstruction. This study aimed to review the recent management of PVF, in particular the role of anti-TNF drugs. Method: All patients presenting for management of PVF to our surgical service between 2007 and 2016 were studied. Median duration of follow...

Operative intervention for Crohn’s disease must include careful assessment of the entire gastrointestinal tract for additional disease that may require intervention. Numerous methods for intraoperative stricture detection are available to the surgeon including palpation, balloon catheter trawl, ball calibration and intraoperative endoscopy. This ch...

The importance of emotional intelligence in the surgical setting.

Early complications of the Kock pouch construction include suture line leakage, bleeding from suture lines, nipple valve necrosis, slippage, and prolapse, stenosis and difficulty with intubation and the general complications of any major intra-abdominal surgery including adhesional obstruction. Complications requiring operative intervention arise i...

Aim Early rectal cancer can be managed effectively with local excision, which is now standard of care for many T1 lesions. However, the presence of unexpected adverse histopathological factors may indicate an increased risk of local recurrence, prompting consideration of completion radical surgery. Many patients are unfit or prefer to avoid radical...

Conventional transanal excision predated any other form of rectal cancer surgery. It was first described in 1739 and further developed in the 19th century. 1 The restricted view and limited range hindered further development and were believed to contribute to the high rates of local recurrence. In 1874, Koch described excision of the coccyx, and in...

Background: Iatrogenic ureteric injury is a serious complication of colorectal surgery. Incidence is estimated to be between 0.3 and 1.5%. Of all ureteric injuries, 9% occur during colorectal procedures. Ureteric stents are utilised as a method to reduce the risk of injury; however, these are not without risk and do not guarantee prevention of inj...

After another GNM judgement is quashed, our profession must focus on systemic pressures as well as individual actions.

Surgery remains the mainstay of curative treatment for primary rectal cancer. For mid and low rectal tumors, optimal oncologic surgery requires total mesorectal excision (TME) to ensure the tumor and locoregional lymph nodes are removed. Adequacy of surgery is directly linked to survival outcomes and, in particular, local recurrence. From a technic...

Background: Standard surgical practice for colorectal cancer involves resection of the primary lesion and all draining lymph nodes. Accurate intraoperative assessment of nodal status could allow stratified resectional extent. One-step nucleic acid (OSNA) can provide a rapid method of interrogating nodal tissue, whilst near-infrared (NIR) laparosco...

Aim: Minimally-invasive, organ-sparing surgery has been used increasingly for early rectal cancer in recent years. However local recurrence remains a concern. This study presents a ten-year single-centre experience of recurrence after local excision for T1 rectal cancer. Method: Data are collected prospectively on all patients undergoing local e...

Objective: To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal Excision (TaTME) and identify independent risk factors for failure. Background: Anastomotic leak and its sequelae are dreaded complications following gastrointestinal surgery. TaTME is a recent technique for rectal resection, which include...

The prognosis of rectal cancer has significantly improved over the last decades since the introduction of the total mesorectal excision (TME) surgery. However, the outcome of lower rectal cancer has not improved to the same degree despite the increased use of neoadjuvant treatment. Large multicentre studies have shown that abdominoperineal resectio...

Medicine needs to come up with its own Marshall Plan to reward, motivate and combat mental fatigue among its ranks.

Purpose: The aim of this study is to assess the quality of IBD guidelines using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. Method: A literature search was and the methodology of the PRISMA guidelines were adopted. All four appraisers were blinded to the scores of the others. Intra Class Correlation (ICC) statistic...

Background Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near‐infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR‐ICG imaging in colore...

AimOur aim was to assess bowel function and its effect on overall quality of life (QOL) when compared to healthy controls after colectomy. Methods Patients undergoing resection of colorectal neoplasia were recruited pre-operatively and followed up at 6 and 12 months, to assess ‘early’ bowel function. Patients who underwent surgery 2 to 4 years prev...

Background: There remains a lack of international consensus on the appropriate management of lateral nodal disease. Although the East manages this more aggressively with lateral lymph node dissections, the West aims to eradicate small-volume disease with neoadjuvant chemoradiotherapy and lateral nodal disease is not considered for routine surgical...

Sometimes surgeons just have to make do with what they’ve got in the time they’ve got.

Background Acute lower gastrointestinal bleeding is a common reason for emergency hospital admission, and identification of patients at low risk of harm, who are therefore suitable for outpatient investigation, is a clinical and research priority. We aimed to develop and externally validate a simple risk score to identify patients with lower gastro...

Ulcerative colitis is a chronic, relapsing idiopathic inflammation of the rectum and variable lengths of the adjoining colon. Onset usually occurs during the third and fourth decades of life and commonly presents with bloody diarrhea. A diagnosis is made using a combination of endoscopic and histological evidence to distinguish it from other inflam...

Lymph node staging in colorectal cancer (CRC) is established by histological examination. Molecular techniques, such as one-step nucleic acid amplification (OSNA), have been recommended by NICE1 for intraoperative sentinel node assessment in breast cancer. OSNA is a relatively novel and simple molecular technique that uses a reverse-transcriptase l...

Is it merely a matter of time before machines become self-aware and take over, terminating the need for human surgeons?

Aim: Subtotal colectomy (STC) is a well-established treatment for complicated and refractory ulcerative colitis (UC). A laparoscopic approach offers potentially improved outcomes. The aim of the study was to report our experience with STC for UC in a single large center. Method: From January 2007 to May 2015, all consecutive patients undergoing...

Objective Lower GI bleeding (LGIB) is a common reason for emergency hospital admission, although there is paucity of data on presentations, interventions and outcomes. In this nationwide UK audit, we describe patient characteristics, interventions including endoscopy, radiology and surgery as well as clinical outcomes. Design Multicentre audit of...

After a tumultuous 12 months at home and abroad, here's to a brighter 2017 for the Bulletin and beyond.

Objective A defunctioning stoma is a therapeutic option for colonic or perianal Crohn’s disease. In the pre-biologic era the response rate to defunctioning in our unit was high (86%) but intestinal continuity was only restored in 11-20%. Few data exist on the outcome of defunctioning since the widespread introduction of biologicals. Material and Me...

Background/Case Studies: Gastrointestinal bleeding is a common indication for transfusion, but it is not known what proportion of this is due to lower gastrointestinal bleeding (LGIB). The aim of this multi-center observational study was to define the patient characteristics, investigations, management and the use of blood in LGIB. This report focu...

Introduction: Lower gastrointestinal bleeding (LGIB) is a common indication for emergency hospitalisation. There are few data characterising its modern day epidemiology, interventions and outcomes. This study describes characteristics, aetiology and management of patients admitted to UK hospitals with LGIB. Aims & Methods: Prospective national audi...

Objective: This study aims to report short-term clinical and oncological outcomes from the international transanal Total Mesorectal Excision (taTME) registry for benign and malignant rectal pathology. Background: TaTME is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. Outcomes have been pu...

The reduction of the incidence, detection, and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on long-term morbidity and healthcare resources has received relatively little attention. C...

Aim: The aim of this study is to describe the indications, procedures and outcomes for patients requiring emergency surgery for lower gastrointestinal bleeding (LGIB). Method: A UK audit of all adults admitted with LGIB in 138 hospitals, between September and December 2015. Surgical teams identified patients and data were entered into a centralised...

Where the surgical profession now stands after a summer of unprecedented political drama.

Introduction: Acute lower gastrointestinal bleeding (LGIB) is a common indication for emergency hospitalisation worldwide. In contrast to upper GIB, patient characteristics, modes of investigation, transfusion, treatment and outcomes are poorly described. There are minimal clinical guidelines to inform care pathways and the use of endoscopy, inclu...

Trying to see both sides of a strike the like of which we have never seen before.

Aim: Outcomes following treatment for low rectal cancers still remain inferior to those for upper rectal cancers. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict...

Aim: Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical adominopelvic approach for rectal cancer. The aim of this study was to report a two centre experience of this technique, focusing on the short-term and oncological outcome. Method: From May 2013 to May 2015, 40 selected patients with histolog...

The real casualty in all this is good will. It is stating the obvious to point out that only the brightest and best get to medical school, that these recent graduates are full of energy and enthusiasm, and they are motivated by high ideals. The NHS is not just an industrial machine run on financial efficiency and production targets even though it s...

This chapter discusses the case of a 27-year-old man who was referred by the gastroenterologists for surgical management of multiple small bowel strictures. He had been diagnosed with Crohn's disease at the age of 22 and had had a laparoscopically assisted resection of 80 cm of jejunum when 23. A magnetic resonance enterography (MRE) demonstrated m...

Risk and negligence in an era of increased litigation.

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We...

Aim: Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique. Method: From June 2013 to September 2014, 20 selected pat...

Plasmons are commonly interpreted with classical electrodynamics, while nonclassical effects may influence the dynamics of plasmon resonances as the plasmon confinement is approaching the few--nanometer scale. However, an unambiguous approach to quantify the degree of nonclassical dynamics remains. We propose a nonclassical-impact parameter (NCI) t...

The place of colectomy with ileostomy formation for acute severe colitis, which does not respond to medical therapy, is well established [1, 2]. For decades surgeons have debated the optimal management of the retained rectal stump. Traditional options after open colectomy included leaving an open mucous fistula, a long rectosigmoid remnant closed s...

Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current e...

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle challenges posed by difficult pelvic dissections in colorectal surgery. As with all emerging techniques, small modifications and optimisation is often required to enhance its efficacy and safety. Designing and conducting valid scientific evaluations of new surgical...

Aim: Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard APE. ELAPE can, however, be difficult particularly in identifying the anterio...

Colorectal surgery is one of the most common procedures performed around the world with more than 600,000 operations each year in the United States, and more than a million worldwide. In the past two decades, there has been a clear trend toward minimal access and surgeons have embraced this evolution. Widespread adoption of advanced minimally invas...

Introduction La fuite anastomotique est une complication redoutée en chirurgie colorectale. Actuellement, aucun moyen ne permet d’évaluer la viabilité de l’anastomose durant l’intervention. Récemment, nous avons décrit la possibilité d’évaluer la microvascularisation d’une anastomose à l’aide d’une caméra néo-infrarouge et de l’injection de vert d’...

Background and aims: Anastomotic dehiscence is one of the most feared complications in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. One of the key factors is the perfusion of the bowel to be joined. Presently, surgeons rely on a variety subjective measur...

While still debated, it was advised to perform a protective temporary ileostomy after a low anterior resection (LAR). This might help to decrease the leak rate and therefore offers the patient better outcomes. Anastomotic leak can occur in many situations after a LAR and the control of the risk factors helps to adapt the need of an ileostomy. Near...

Background: Noninflammatory masses in the ischiorectal fossa are rare. Objective: This study aimed to review our experience with ischiorectal fossa tumors and to address the question of whether percutaneous biopsy should be undertaken. Design: This is a retrospective study. Settings: This study was conducted at a tertiary institution. Patie...

The Internet is a vast resource for patients to search for health information on the treatment of Crohn's disease. This study examines the quality of Web sites that provide information to adults regarding Crohn's disease, including treatment options and surgery. Two search engines (Google and Yahoo) and the search terms "surgery for Crohn's disease...

We’ve made our beds – now let’s hope there are enough to lie in.

Major changes to our digital publications are just around the corner.

Introduction Iatrogenic ureteric injury is a serious complication of colorectal surgery. Fluorescence image guided surgery (FIGS) is an expanding field and can potentially make operations safer for patients and prevent inadvertent ureteric injury. Intravenously administered methylene blue is excreted renally and concentrated in the urine. It is flu...

Will surgeons conquer the final frontier? Or will E(N)T phone home?

Colectomy for ulcerative colitis can be followed by ileal pouch formation to enable restoration of bowel continuity. Patients with familial adenomatous polyposis may also undergo pouch formation. The most common long-term problem with pouches is pouchitis, though this can often be treated with antibiotics. Stomas come in many forms but the most com...

The goal of business today is to unlock intelligence stored in data. We are seeing a confluence of trends leading to an exponential increase in available data, including cheap storage and the availability of sensors to collect data. Also, the Internet of Things, in which objects interact with other objects, will generate vast amounts of data.

AimEarly pT1 polyp colorectal cancers (CRCs) present challenges for accurate pathology substaging. Haggitt and Kikuchi stages depend on polyp morphology and are often difficult to apply due to suboptimal orientation or fragmentation, or absence of the muscularis propria in polypectomy or submucosal resection specimens. European guidelines for quali...

AimIdentifying predictors for recurrence of Crohn's Disease (CD) after surgery to improve disease surveillance or targeted therapy is rational. The purpose of this study was to examine the relationship between the myenteric plexitis (MP) and clinical or surgical recurrence.Method Between 2000 and 2010, patients who underwent primary ileocaecal rese...

In the first issue of the new-look Bulletin, we discuss politics and determinism – both nominative and architectural.

Transanal endoscopic microsurgery (TEM) enables organ-preservation after rectal tumour surgery. Its application is being expanded using adjuvant and neo-adjuvant treatments. Our object was to evaluate the changes over time in anorectal function, urinary symptoms and quality of life (QOL) in patients who had TEM surgery for a rectal tumour. Between...

AimThe study examines the quality of websites that provide information on ulcerative colitis, including treatment options and surgery.Method Two search engines (Google and Yahoo) and the search terms “surgery for ulcerative colitis” were used. The first 50 sites of each were assessed. Sites were evaluated for content and scored using the DISCERN in...

Loss of heterozygosity (LOH) of the adenomatous polyposis coli (APC) gene triggers a series of molecular events leading to intestinal adenomagenesis. Haploinsufficiency of the cohesin Rad21 influences multiple initiating events in colorectal cancer (CRC). We identify Rad21 as a gatekeeper of LOH and a β-catenin target gene and provide evidence that...

Dear sir, Laparoscopic mobilisation of the splenic flexure can be challenging, but necessary at times to ensure a tension-free colorectal (or indeed coloanal) anastomosis. We favour the medial to lateral approach, with high tie of the inferior mesenteric vein. Hazards encountered during this approach include potential damage to the pancreas, splee...

Dear sir, Parastomal hernia is the most common long-term complication after radical cystectomy and ileal conduit diversion, occurring in approximately 30 percent of patients (1). Most parastomal hernias are asymptomatic and can therefore be treated conservatively. The primary indication for surgical repair is poorly fitting ostomy appliances due t...

There has been a succession of articles and commentators lamenting the demise of traditional anatomy teaching over the past ten years. Yet it is interesting to see this issue’s piece by Steven and Whiten on The Evolving Role of the Anatomy Demonstrator, which shows that although much has changed the model is still durable. While many trainees are n...

By any measure, anastomotic leak is a devastating complication of colorectal surgery. There is currently no accepted or widespread method in use to assess the viability of a colorectal anastomosis in situ. Here in this video vignette, we detail the use of near-infra red (NIR) laparoscopy to confirm perfusion adequacy of digestive anastomoses by mea...

Introduction: Endorectal ultrasonography (EUS) is used to T stage early rectal tumours and select patients to whom transanal endoscopic microsurgery (TEM) could be offered. Published papers have shown that EUS can have good accuracy, but there is little literature on how EUS influences patient management. The study aim is to ascertain the value of...

Low mesorectal dissection can be difficult and we find it helps to do some of the lowermost part of the TME dissection from below using a transanal approach. This also needs some modification of the typical mechnical stapling method in order to allow the standard circular stapling devices to be used.The transanal approach allows for double purse-st...

In stage III colon cancer oxaliplatin/5FU-based adjuvant chemotherapy (FOLFOX) improves disease-free survival (DFS) and overall survival (OS). In rectal adenocarcinoma following neoadjuvant chemoradiation (CRT), we examined the benefit of postoperative adjuvant capecitabine and oxaliplatin (XELOX) chemotherapy. Eligible patients were randomly assig...

Background Robotic transanal minimally invasive surgery (TAMIS) may be an option for rectum-preserving excision of neoplasms. Recent cadaveric studies showed improved vision, control and manoeuvrability compared with use of laparoscopic instruments. This study reports the clinical application.Methods Consecutive patients eligible for transanal endo...

Interstitial cells of Cajal, expressing the proto-oncogene c-kit, have been shown to regulate the spontaneous activity of the gastrointestinal tract. They have been described in the human internal anal sphincter; however, their function is still unclear. We examined the effects of the c-kit tyrosine kinase inhibitor imatinib mesylate on sphincter s...

Anastomotic leakage is a devastating complication of colorectal surgery. However, there is no technology indicative of in situ perfusion of a laparoscopic colorectal anastomosis. We detail the use of near-infrared (NIR) laparoscopy (PinPoint System, NOVADAQ, Canada) in association with fluorophore [indocyanine green (ICG), 2.5 mg/ml] injection in 3...