Colorectal Surgery - Science topic

Schwandner F, Klimars U, Gock M, et al. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg. 2020;24(2):411-417. doi:10.1007/s11605-019-04171-7

A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.

Thanks

Could you possibly describe your technique to us Dr. Hofer?

It seems that Dr. Dwivedi has opened up a can of worms with his question ! I think this is a very relevant and pertinent question, with pilonidal sinus being a common problem, notorious for its recurrence.

I agree with Dr. Naqvi - there is a theory for recurrence in a hairless cleft. It's most likely due to the hairs that fall from the head down the back and eventually into the cleft.

Thank you Dr. Castillo,

I feel the problem lies in the absence of any appellate body for the proper nomenclature of human body parts.

Chemistry recognized the problem very early and came up with a sophisticated system called IUPAC (International Union for Pure and Applied Chemistry) nomenclature.

I think it is the prime responsibility of the the Anatomists and Physiologists to come forward and establish a commission for the nomenclature of body parts and functions. It seems just simple right now, but as the fashion of naming every single entity as a separate organ grows, it will be a problem to tackle the issue then.

There was recently a new floating that human body consists of some 78 organs and Mesentery is the 79th in the list. I am afraid that I don't know who generated that list. This list was most probably a bogus list or the journalist's flaw.

Additionally, the Lancet paper published by Prof. Coffey does not seem to be sufficiently justifying the organ status of Mesentery. Because, in order to do that, it is important to place the definition of an organ in the introduction itself. The paper by Coffey and his colleagues is just a review trying to give an idea that based on the endoscopic experiences and other speculative approaches, Mesentery may be a continuous entity from Jejuno-ilial junction to rectum. I do agree to this statement because we have done a number of cadaveric dissections and found that Mesentery is a continuous entity. But that is no justification to refer to Mesentery as an organ.

But we don’t heal the proper mechanism of the microscopic disease , i.e , cell spreading....

Patient recieved adjuvant chemotherapy and is on surveillance more than 2 years, disease free. No rerescection required

she underwent flexible sigmoidoscopy every 6 months

Discuss it in a multidisciplinary committee, it is a question that involves considering many details

It is of course true that cardiac catheterization carries a negligible risk of bacteremia but with PCI bacteremia occurs frequently (in approximately 30% of cases); however, clinical sequelae occur rarely in such cases. PCI has a greater bacteremic potential, probably because of the length of the procedure and the repeated insertion of interventional devices into the vascular system . Infective mycotic aneurysm presenting as transient acute coronary occlusion and infectious pericarditis [Badshah A, Younas F, Janjua MSouth Med J. 2009 Jun; 102(6):640-2.]

Dear collegue,

I guess that the diverticula formation can have more than one mechanisme. In old patients it can be the weak muscle together with the death of the neuronal components , it leads to the hypokinetic constipation, bacterial hyper growth and toxic damage of the mucosa and sumucosal layer.  In other case the main reason can be the direct hypoxy of the muscular layer after the  enlargement of the colon. So it is necessary to study the case-records and the resulte of the R-study of the colon 

I think most of us would surgically excise the abnormal tissue and get a pathology report.

Dr Prasanna Kumar Reddy

Since this is cT1 N0, mod differentiated adenocarcinoma 1cm above dentate line, addition information on tumour size and persentage of circumference involvement may indicate the possibility of a Trans anal wide excision..

LAR

Look there was very early recurrence. This patient is young and high levels of gastin will remain everytime. So new carcinoid tumors will always return.

What would be your approach in a fit 50 yr old patient with these characteristics? Chemoradiotherapy with 25 fractions and capecitabine?

Dear Nigel,

Based on the local recurrence rate of rectal tumors, the National Cancer Institute establish the length of the rectum to be 12 cm above the anal verge (> 12 cm, local recurrence same with colon cancer; < 12 cm local recurrence similar with middle rectum).

From a classical & surgical point of view, the upper limit of the rectum is at the third sacral vertebra, and the inferior limit is represented by the anal verge.

However, a universally accepted length is 15 cm from the anal verge, and may be divided into three segments:

Other clinicians are considering 0-5 cm, 5-10 cm, 10-15 cm as boundaries for lower, middle and upper rectum, respectively. 

On the other hand, in Gray's anatomy there are two different anatomical structures: anal canal and rectum.

The anatomic anal canal is 2 cm long (anal verge-dentate line), while the surgical anal canal has a length of 4 cm from the anal verge (anal verge - puborectal muscle).

Measurement of rectal tumors from the anal verge should be done with a rigid proctosigmoidoscope and not with a flexible instrument which introduces an important degree of variability.

The management of recurrent rectal cancer depends on re-staging it the same way you would any primary tumour, with histology/CT/MRI/PET CT/Bone Scans. This provides staging of the local disease along with ascertaining the presence and extent of distant disease, if any. Of course, the specific treatment would depend on the stage and treatment given first time around, specifically the amount of radiotherapy that was used. A lot of oncologists do offer some radiotherapy for the recurrence, using more targeted techniques. Then, depending on the involvement of other pelvic organs, resection is possible, usually in the form of an appropriate pelvic excenteration. It is best to approach such a resection along with other specialists, commonly, a Urologist (for the construction of an illeal conduit in place of the bladder), an Orthopaedic or Spinal surgeon, for the sacrectomy; a plastic surgeon, particularly as it is likely radiotherapy has been used and a local flap reconstruction may be required for the perineal defect; a vascular surgeon, if the iliac vessels have been encased, and in women, a pan-hysterectomy with a partial vaginectomy might be needed. It is better to start out such ventures with a fully established team as it is a completely different ball-game compared to just converting an anterior resection into an APER. The results, however, are rewarding; and are similar to those obtained following an anatomically curative liver resection for colorectal liver metastases i.e. 30-40% 5 year survival. In the UK, there are only a handful of centres that offer the complete service, and this is with good reason! See data published by Prof Peter Sagar, Leeds, UK, amongst others.

HIPEC is not commonly required, as rectal recurrence is usually infraperitoneal, though locally advanced. Recurrence of an intraperitoneal colonic tumour is a different matter. Here, once again, it is imperative to obtain tissue diagnosis and complete staging, particularly looking for distant metastatic disease, with a CT/MRI/PET CT etc. The extent of involvement determines the resectability of disease. i.e. one would not simply debulk colorectal disease and perform HIPEC; the aim is to remove all visible macroscopic disease, via visceral peritonectomy, which is a procedure resulting in significant morbidity and mortality on; HIPEC is an adjuvant measure, not therapeutic on its own. For UK data, see that published by Brendan Moran, Bassingstoke.

The take-home message is that recurrent colorectal cancer includes a wide spectrum of disease; some easily manageable locally by all colorectal surgeons; the rest requiring not only highly detailed work-up and discussion, but then specialist teams used to dealing with such cases. Given the variable resources internationally, inevitably, there is a limit to what is available in different nations; and, vitally important, what patients and organisations are able to afford. A case that one would refer to a specialist centre in one nation would inevitably be deemed futile for surgical intervention in another. We all work within the local realms of possibility. Thus, while I would stretch to develop local expertise, I would ensure I did not provide my patients false hope or declare them unsuitable for any treatment. Though an inoperable rectal recurrence often remains limited to the pelvis till the patient succumbs, it is a miserable condition to suffer from, and requires a lot of specialist care to ensure the patient's last days are as comfortable as possible. Once inoperability is established and decided, I would plan to convert to an end-colostomy sooner after than later. Established ancient techniques for debulking including alcohol injections often come in handy towards the end.

In the majority of the patients we remove epidural after 2-3 days   we also use  dipirone as a reliable pain killer drug with few side effects We also have a Pain group that manage most of these patients

Maybe they are:

 http://hub.hku.hk/bitstream/10722/209298/1/content.pdf?accept=1

can it be possible to extract the stent trans anally?If this is possible we will get a higher anastamosis.I am not quite clear about the question.

This is sensible as such features goes with tuberculosis and in developing countries, this should be the first possibility that should be looked for.

Remember, Common things are common. 

на операции эпидуральная и общая анестезия, в послеоперационном периоде-первые сутки-эпидуральный блок, далее трамал и кеторолак.

Dear Dr Afrasanie

Inorder to decide that patient can benefit from liver metastasectomy , we should have all liver plan and radiologist should say about future liver remnant (FLR) , it should be more than 20% in normal situation and at least 30% in patient who received chemotherapy.

Besides we should be sure about extra liver situation such as lung metastasis.if there are mets in lung it should be operable.

For better judgment about how many mets in liver or lung , new studies recommend PET CT scan.

However for yours patient , according one cut of liver , it seems to be at least borderline or inoperable . In optimist situation, neoadjuvant chemotherapy in orer to down size of tumor or left portal vein embolisation in order to hypertrophy of right liver lobe is an option to have a secure FLR.

Good Luck.

I agree with both the above. Consideration of forming stomas might be common-place for some health-care providers, but there is the overwhelming majority of patients, belonging to a large variety of cultural backgrounds where the very idea of having a GI stoma is scary, unsavoury, non-religious and unhygienic, to mention a few feelings. In such circumstances, a nurse who is both surgically educated and culturally sensitive forms the vital supportive common denominator to patients and surgeons alike. Despite the desire to do so, surgeons are unlikely to have the time to alleviate patient apprehensions regarding stomas; stoma nurses are able to do that. Further, there is a lot of practical information patients often seek, specifically in nations where public health services are either not available or are of highly variable standards. As far as colorectal surgery is concerned, particularly in the elective scenario, if I was fortunate to have the choice of one specialty nurse, it would be a stoma nurse. Over the years, stoma nurses I have worked with have easily extended their skills into covering colorectal cancer, IBD, anorectal physiology, urogynae and abdominal wound care nurses. The stoma nurse has become indispensable to our practice such that whenever a junior colleague asks me what to look for in a potential employment, stoma nurses hold an equal position on that list as other medical colleagues. Yes, get one - and if you're lucky enough to do so, cherish them!

Dear Dr Negar

Thanks for your attention. according NCCN ver 2,2016 for sessile polyp ,two option was recommended but regard to patient history of cancer i am keen to surgery.

Thanks. And though I think you're right, as we do learn of definite "proven" contributory factors,new have a duty to alter our practice accordingly. If I had a crystal ball I would say that in another 2-3 decades, at least in cancer, resections will go out of the window. We will be using individual patient-tumour targeted bio pharmacology for treatment,msuch that all that would be left is a small lesion, requiring a minimal local excision, if that! I guess the message is embrace developing wisdom - and, it appears in surgery that wisdom is heading towards a minimalistic approach, which will hopefully reduce leak rates to 0, even if that means no surgery. The more risk factors we understand, the more we take an individualistic approach in our recommendations hence, science provides us the justification for an intelligent, philosophical and ethical approach. For instance, if our risk stratification gives us a possible leak rate of 80% and individualised neo-adjuvant chemo-rad a pCR rate of, say 50%, would we ethically be able to recommend resection as the first course? Science is progressing rapidly; we cannot predict whether we will know all the answers to a particular issue - all we can do is be willing to change, intelligently, rather than change for the sake of change! There - a more philosophical approach!

Royal Devon and Exeter Hospital will be taking part in the ESCP closure of intestinal stoma audit

Hello  Michael,

I have ZERO experience in the medical imaging field but have over 40 years of experience with digital image analyses of satellite, aerial, and shipborne imaging (remote sensing) of the Earth surface (including acoustic imaging of the ocean surface) .  I have an interest in the application of some of the capabilities developed over 4 decades in remote sensing to the medical field.  I think that my expertise related to radiometric and geometric calibration, change detection, and spatial variability analyses might be useful in the medical field.   I retired from the federal government (USGS) after 38 years and currently am an adjunch research professor.

If you think this might be of interest let me know.

Pat

Probably the same Idea as ruberband ligature for Hemoroids

Look at the large trials to date - COLOR, CLASIC etc. They provide good definitions for this subset, which will make your decision easier.

To my knowledge the best evidence we have so far is in the form of retrospective observational trials. See the two attached cohort studies. I believe there is a RCT currently underway addressing this question in major abdominal surgery however. 

The rational behind the wasteful watching principle in patients complete regression following neoadjuvant radiation and chemotherapy for mid and low rectal cancer is truly alluring. However, a series of issues still need to be addressed with regard with this treatment option.

First: 

Hello Dr. Dwivedi, I have seen some anterior fistulae that look like they open directly into the anal canal on clinical exam, and eventually turn out to be a complex posterior fistula with an anterior opening, i.e. a posterior fistula can fistulate all the way round and open out into the anterior half, and even into the vagina. Also, I suspect, but have no evidence for this, that there must be instances where multiple anal glands might become infected, extend outwards, and perhaps connect with other infected glands elsewhere in the anal canal. My advice would probably be that unless it is extremely obvious there is an anterior fistula with an obvious radial internal opening, always be suspicious there might be complex fistulation. MRI is very helpful, but I have found the usefulness of these depends a lot on the experience of the radiologist in interpretation. I hope that helps.

No, no negative issues. May fade at different speed, depending on patient type and related perfusion. Clipping may be easier to find as you can xrays. or you combine both.

If it is a congenital ano-vestibular, it will have an epithelial lining. If it is, then does it cause enough symptoms to warrant excision? In infants I would normally excise with a covering colostomy, but I know that in places where there is a lot more experience (India & China) it is often done without.

Thank you so much Dr. Roy 

collagene plugs can be used but the success rate is low. As it's without rusk why not trying to avoid a new intervention. To be successfull collagene plug neds to be inserted on a clean fistula ( no collected infection) so use irrigation before.

Take a Biopsy 

Video Assisted Anal Fistula Treatment (VAAFT) is a good option in recurrent high FIA. It allows visualization of the main and side tracks and possibly the internal opening as well. It can be both diagnostic and therapeutic.

I agree with A Julianov that we use the term of " completion surgery" only for those cases requiring surgery  In case of unfavourable histology after TEM, or positive resection margins . Conversely, The "salvage surgery" is used for a surgical procedure performed  for recurrence after a full-thickness transanal excision for Stage I rectal cancer. In both cases a TME- proctectomy  is the surgical procedure of choice and the sphincter preservation is mostly possible. But  in both cases, the results aren't equivalent .

In fact , if  no difference was found in outcome between patients with rectal cancer undergoing  TME-proctectomy  after TEM and those undergoing primary TME , in case of  Salvage surgery for recurrence after local excision of rectal cancers  it may not provide results equivalent to those of initial radical treatment.

Tech Coloproctol. 2013 Aug;17(4):397-403.

The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study.

Levic K1, Bulut O, Hesselfeldt P, Bülow S.

J Surg Educ. 2008 Jan-Feb;65(1):67-72. 

Early rectal cancer: local excision or radical surgery?

Chang AJ1, Nahas CS, Et al.

Dis Colon Rectum. 2002 Jul;45(7):875-9.

Salvage radical surgery after failed local excision for early rectal cancer.

Friel CM1, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguílar J.

This reference is the best I can suggest to answer the question. In my experioece, I agree with the above regarding right hemicolectomies and chewing gum if patient isn't tolerating fluids particuarly well.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg. 2013 Feb;37(2):259-84. doi: 10.1007/s00268-012-1772-0.

By local repair eventually using staple-fixation:

Ecker KW, Schmid Th, Xu HS, Feifel G: Improved Stabilization of Conventional (Brooke) Ileostomies with the Stapler Technique. World J Surg 1992; 16: 525 – 529

The patient should measure ileostomy output for 2 days. If over 1200 ml per day, start taking loperamide  up to 16 mg (8 tablets) per day, taken in divided doses before meals and at bedtime.

Eat 6 small meals per day rather than 3 larger ones.

Try limiting fluid intake with meals. Still make sure you are drinking 8-10  cups of fluid per day.

Avoid high fiber foods.

Limit or avoid caffeine and high fat foods.

thank you very much

Jo

GB and I were discussing this very recently and are keen to explore this further. Have you seen these composite risk tables in a very well written open access article by Taylor and hosie:

The tables they present are very thought provoking NNT by completion TME after clear excision of a T1Sm2 to acheive one life saved at 5 yrs is 40!....This is in a young fit patient & ignoring morbidity of TME!

There are also some interesting articles on patients surprising willingness to gamble life expectancy to avoid morbidity.  A recent systematic review I'm sure you have already seen:  Colorectal Dis. 2014 Aug 23. doi: 10.1111/codi.12754. [Epub ahead of print]  A systematic review of patient preference elicitation methods in the treatment of colorectal cancer.  Currie A1, Askari A, Nachiappan S, Sevdalis N, Faiz O, Kennedy R.

Never, because the peritoneum generally doesn't meet easily and small gaps will be left (which are much more dangerous than big gaps for causing internal small bowel obstruction). Its the same reason I never close mesenteric defects after segmental resection.

Of course, the aspects of anaesthesiology are important, and part of the preoperative preparations. Comprehensive geriatric assessment is, however, much more: The key is to determine the biological reserves - or biological age - of the individual elderly patient, which often differs from the chronological/calendar age. A 90 year old person may have the biological reserves/age of a 70 years old person, and vice versa. There are a number of publications from the above mentioned group of authors that describe CGA clearly, and which impact it has on outcomes in colorectal surgery in elderly patients. Frailty is one of the most important predictors of poor surgical outcome in elderly, and worthwhile to assess preoperatively. Knowledge about and implementation of these aspects would in my opinion define a geriatric colorectal surgical service.

Let’s go for the Nobel prize! I prefer hemorroidectomy with ligasure. It is expensive but give less blood loss and pain with nice cosmetic results. I do this only if banding fails. I tried the pexy technique. Results were pain and recurrence. With the Milligan Morgan you resect less tissue than the ligasure. I am still a little skeptical about the laser.

Suturing of pelvic peritoneum is life saving to avoid peritonitis in case of likage.

Usually we pu two drains. In case of leakage with stable patient, Iirrigation with betadine ghrough one drain and 

I combine a fistulectomy with  a rectal advancement flap  and a Cook fistula plug and have a succes rate of 75 %. The first 30 cases are in press, albeit in the Acta chirurgica belgica because " Colorectal disease turned it down. The OTSC was proposed to me but I am reluctant to use because  of 1° its cost and 2° it's  fate . What happens when this huge thing stays clinged in the anal canal.  As Dr. Benesch states I guess it can be  painful . How do you get rid of it  when it's not useful anymore ????

Perianal Crohn's disease might first present this way.

Dr. Alawad, A similar detailed discussion was initiated by Dr. Alfie on June 24, 2013

I think that surgery is an handcraft work. Despite a lot of reviews and EBM scientific paper an eclectic way of thinking is essential in surgery. Like " the only good knot is the right one" we can say that "the only good anastomosis is the right one". Often also a stapled anastomosis needs a tailored execution , adding , ad example , a running suture tu assure hemostasis of stapled line.

When you respect the three holy principles of good blood supply , tension free and impermeability , the technique of anastomosis is irrelevant.

Regarding Bowel Prep we had published an article summing current evidence:

Deka P, Negi SS. Role of mechanical bowel preparation before colorectal surgery. National Medical Journal of India 2009;22(1):7-8.

I think I will. Thanks

A photo of a patient who underwent laparoscopic sigmoidectomy by an umbilical zigzag skin incision technique 1 year ago. Can you see the scar? Almost invisible!

In my practice, I culture all cases of perineal abscess, and if E. coli is grown, I tell the patients that fistula is highly likely.

Reference: Elsevier Saunders Publisher; A Companion to Specialist Surgical Practice; Colorectal Surgery; 3rd Volume; Edited by Robin K. S. Phillips; Chapter 13; Page 244

Straight coloanal anastomosis may be related to higher evacuation frequency and the occurrence of fragmented evacuations, while colonic pouch is related to better functional results and more predictable evacuations in early evaluations. although long term evaluations show almost no difference between straight or pouch anastomosis, it must be considered that some patients will not have "long term" evaluation, which makes this issue important. this is why i always use J-pouch when I have to do a ultra-low rectum or anal canal anastomosis.

I also prefer MRI imaging followed by drainage via seton. In complex fistulas you can leave the seton for several months. The major aim is to avoid surgery near the sphincter, as many patients will undergo multiple operations and the preservation of sphincter function is crucial for their QoL.

The appendices epiploicae, are small pouches of the peritoneum filled with fat and situated along the colon and upper part of the rectum.

They are mainly the appended to the transverse and sigmoid colon, however, their function is unknown.

The appendages can become inflamed, a benign but painful process known as epiploic appendagitis which can mimic acute appendicitis and other conditions.

I published One case study seen in 1995 in UK as Registrar. We opened him due to signes of acute abdomen and CT findings were Internal Herniation. At laparotomy I found two appendices epiploicae, were joined at tips inflammed causing a Ring where the small bowel were herniated.

The primary morphological changes are the development of adenomatous polyps. However, the only method is to perform an endoscopic examination to animals with a dedicated instrument. “Coloview miniendoscopic system”, consists of a miniature endoscope (scope 1.9 mm outer diameter), a xenon light source and a triple chip camera (all from Karl Storz, Tuttlingen, Germany). his method is expansive, but allows to avoid the sacrifice of the animals.

I have changed my practise over the years. While training in HPB, as a protocol were putting T tubes across all HJ's performed(Whipple's, biliary strictures etc). I did not see any complication related to the T tube( no leaks because of T tube, no infection etc). The advantages were to monitor the colour of the bile, output, could flush the tube if there was thick infected bile or sludge etc and we would perform cholangiogram always before removal of the T tube. Patients who had cholangitis preop or had thick sludge in the bile duct where the tissues were friable and thin, putting a stent gave a sense of relief even if there was leak(controlled fistula). However the disadvantage from patients perspective was a tube sticking out and the need for a visit to pull the tube out.

I changed and started putting T tubes selectively in patients with cholangitis and who had thick infected bile. The size of the duct was not a criteria to decide regarding T tube insertion. In living donor liver transplant, where the ducts are small, many times more than one duct, I never place a T tube(except in post transplant situation if there was a need for HJ - reason being while on steroids and other immunosuppressants tissue healing is compromised and here the stent would stay for a long period).

As far as transhepatic stents are concerned, if there were PTBD catheters placed preoperatively for any reason( hilar cholangio- biliary decompression etc), these catheters were placed across the anastomosis, otherwise I do not feel the need to place transhepatic catheters preoperatively.

I do not think that diverticular disease is the only cause of lower gastrointestinal bleeding. In emergancy settings a CT scan may be indicated only after a proctologic examination does not find other source of bleeding (haemorroids, fissures, rectal or anal polyops, solitary ulcer syndrome). Anyway, a successive colonoscopy is mandatory expecially in old patients.

We wash out for the simple reason to remove faeces from the rectum to ease the passage of the staple gun.......although I secretly believe it may affect luminal recurrence although it assumes you perform the Moran Triple Stapling Technique of a second transverse stapler below the first, if not any tumour cells or distal limit of the tumour are potentially already in the anastomosis!

Usual cases can be managed according to usual references but unusual cases are challenging!

The identification of a definite point of obstruction, the ‘transition zone’, with dilated small bowel loops proximal to the site of obstruction and collapsed loops distally, is the most reliable CT criterion for diagnosing small bowel obstruction .

Dr Dwivedi, my only reservation in empiric use of Antituberculous therapy is that we often keep in mind only two scenarios that either the patient has tuberculosis that will get better on ATT or it won't be tuberculosis in which case it won't be affected..

In real life, however, there are many more scenarios that can exist, which this simple assumption will fail to recognize.. the patient, for example, can have multidrug resistant TB (an entity not uncommon these days, especially in southeast asia) in which case he won't get better even on ATT.. or the patient has a complex fistula that goes in temporary remission following discharge and some drainage, and we might attribute the response to ATT, thus subjecting the patient to a full course of therapy..

maybe i am being overcautious, but in this day and age (of antimicrobial resistance and its global permutations) empiric treatment of tuberculosis with a premise that if it gets better, then it is TB might not be in overall benefit of the community..

attempts to diagnose TB can be made by sending the pus from fistulas for acid fast bacilli, and pathology from the fistula tract for routine histopathology as well as mycobacterial PCR since the culture yields are not very high..

regards, raza

In a young patient, previously fit and well, with foregut pain and vomiting with no physical signs surely biliary colic is high in the list of differentials.

I can see no indication for antibiotics, no mention of blood tests (WCC/CRP, amylase, LFTs) and no mention of the key and least invasive and most important investigation in this case: an abdominal ultrasound looking for gallstones.

Not to mention specifically mentioning the negative finding of no inguinal/femoral hernias - essential if you are considering even subacute/partial SBO in a patient with a virgin (not previously operated) abdomen.

This presentation is very common on our acute surgical take in the UK.

Gynae history is essential also (LMP, History of PID, Beta hcg etc).

To sum up: management depends on diagnosis (not clear here), which depends on history, examination and special investigations.

What are you treating with the antibiotics?

BW,

John.

The response is Yes, the radiotherapy has to be used if the satging is T3/4 or/and N+

one important data: the Sweden short course radiotherapy is effective to decrease the local recurrence risk.

In practice for

- rectal cancer T3/4 or/and N+ CRM>1mm with an important liver involvement. The treatment of liver met is the priority and a preoperative 5X5gy is a good choice to avoid 3 months wihtout effective chemotherapy

- rectal cancer T3/4 or/and N+ CRM<1mm with an important liver involvement. the treatment is difficult and depend of other additional factors

- rectal cancer T3/4 or/and N+ with a little liver involvement. A long course of radiochemotherapy has to be used. The residual question is the moment of this treatment. But this is antoher question

In addition to my Question

Perineal hernias after aper were seen in about 8% patients. Omentopexy and soft tissue closure alone do not prevent perineal hernias. No Patient with pelvic floor reconstruction (flaps/mesh) developed perineal hernia. However incidence of wound infection and dehiscence ( p=ns) seemed higher after biological mesh.

PPT attached

We have used the standard TEM the SILS port (covidien) and the TAMIS platform we like the TAMIS and SILS ports because we can use standard laparoscopic instruments and energy devices. The SILS limitations have be with keeping the port inside and keeping insufflation. The TAMIS works very well and has a kit that is available for practice and teaching of residents. The ability to move between platforms has worked best for our patients but the TAMIS port seems to be the easiest to use.

The first Dutch study was aborted because of high rate of complications, but other three study are on going. The UK CReST Trial, a second Dutch trial and a swedish trial. I think that we have to wait these results for better understanding the value of the procedure.

There are studies as Intergroup trial INT-0089 [EST-2288] demonstrating that the number of lymph nodes examined in CRC surgery may be associated with patient outcome.So the NCI and AJCC sponsored panel recommended that at least 12 lymph nodes should be examined in patients with CRC to evaluate the nodal involvement. At our center if the pN0 is based on evaluation of <12 nodes the N-staging is considered inaccurate and patients received adjuvant chemo.

This is just part of a package of measures to minimise the disturbance to physiology through either open or laparoscopic surgery and calorific nutrition may be given either as food or nutritional supplements that are absorbed in the upper small bowel.

I always do protective defunctioning transversostomy after resection for mid- and lower third rectal cancer, irrespective of the type of anastomosis (double-stapled, hand-sewn coloanal). After resection for upper third rectal cancer I usually do not divert, excluding very high risk patients. Before 4-5 years there was different policy in my team – after reconstruction we put two tube drains transperineally on both sides of anastomosis and did meticulous peritonisation of the pelvis. If leak occurs we started irrigation-suction of the pelvic cavity through perineal drains, stopped oral feeding and started antibiotics and parenteral nutrition. In one our publication we concluded that this policy is able to prevent fatal complications of anastomotic leak after LAR with TME. And that is truth, but the patients with leaks had very long hospital stay if treated like that. On the other hand their quality of life is very poor because of the need to keep drains in place for a longer periods. And finally in a series of about 50 pts with leaks there were 2 pts who needed a diverting stoma because of high fecal output from the drains. So, we changed our policy.

In our centre both oncology and HPB surgery see every patient, even the initially unresectable patients since some of these will become respectable in the future after chemotherapy. This is important since a portal vein embolization or a staged resection can render some of these patients operable but the opportunity may be missed if surgery is not also following these patients. After the initial visits the patients are presented at HPB Tumor Board. The oncologists, surgeons, interventional radiologists, and radiation oncologists are present, every one is trying to determine how many patients can be converted to a resectable state, i.e. everyone believes that a resected patients is better off. There is no question about the patients that is resectable at presentation, barring other medical conditions they will be offered surgery. it is important that every centre bring all the parties to the table and have a discussion driven by the literature and get buy in for an in-house protocol for these patients, this may need to be done every 2-3 years. The protocol should reflect the centres strengths and attempt to boost their weaknesses.

Defunctioining seems to work. I think it must be personal preference but still believe that ileostomy is supported by some kind of evidence. Bowel prep or not does not seem to make incidence of leak worse (see thread after other question on this site regarding that point). I can't see the logic in the arguments around ileostomy if prepped and colostomy or not. If the bowel is non prepped then there will be some stool above the anastamosis no matter where the proximal defunction is (and there is only 30-40cm or so difference between ileostomy an transverse defunctioning colostomy, leaving more than enough faeces distally to cause sepsis and death if moving through the leak). The bottom line here is that there is no need to prep the colon. if there is no need, we shouldn't do it (all interventions can cause complications).

Just to clarify, this from the Cochrane Review on this topic:

"Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found."