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Background: The aim of this study was to assess the accuracy, particularly the predictive value, of locoregional clinical rectal cancer staging (cTN) and its variability in a national improvement project., Methods: cTN stages and the distance between tumour and mesorectal fascia (MRF) were compared with histopathological findings in 1168 patients who underwent radical resection without neoadjuvant treatment. Data were registered prospectively from 2006 to 2014., Results: Agreement between clinical and histopathological TN stages was 50%, independent of tumour location. Inter-hospital variability was within 99% prediction limits. Magnetic resonance imaging (MRI) was increasingly applied, but staging accuracy did not improve. Stage II-III was correctly predicted in 69% and pStage I was over-staged in 35%. The positive predictive value of endorectal ultrasonography (ERUS) for T1 lesions was 57%. MRI-based distances to MRF correlated poorly with the circumferential resection margin (r = 0.26). A negative resection margin was achieved in 91% when the distance to the MRF was >1 mm., Conclusions: The accuracy of rectal cancer staging in general practice should be improved to avoid under- or overtreatment. Training and expert review of pre-treatment MR imaging could be helpful. A second ERUS is justified when transanal local resection for early lesions is planned.

Purpose: A low pelvic anastomosis is associated with a substantial risk of leakage. A defunctioning stoma (DS) reduces the clinical anastomotic leak rate and the need for re-operation, but stoma closure has its own risk of morbidity and mortality. This study aims to audit morbidity and mortality after loop ileostomy (LI) closure., Patients and Methods: The medical records of 197 consecutive patients who underwent closure of a defunctioning LI between August 2003 and July 2008 were reviewed. Postoperative morbidity and mortality were recorded., Results: Transverse closure of the enterotomy was performed in 149 patients (75.6%), segmental enterectomy with hand-sewn end-to-end anastomosis in 26 (13.2%) and stapled side-to-side anastomosis in 22 (11.2%). Overall postoperative morbidity and mortality were 32.0% and 0.5%, respectively. The surgical complication rate was 30.5%, including prolonged ileus (11.2%), small bowel obstruction (4.1%), anastomotic leak (3.0%) and wound infection (4.6%). Surgical complications were more frequent in male patients (p = 0.005). Prolonged ileus was more frequent when the interval to stoma reversal exceeded 12 weeks (14.3% versus 3.5% ; p = 0.02). The incidence of complications was not influenced by the closure technique. Nineteen patients (9.6%) required re-operation for anastomotic leak (n = 8), wound infection (n = 1), small bowel obstruction (n = 3) and incisional herniation (n = 7)., Conclusion: LI closure is associated with clinically relevant morbidity and mortality. This association should be taken into account in the context of a routine DS policy and should be part of the patient's information.

Background: PROCARE, a Belgian multidisciplinary project on rectal cancer (RC), will be launched in 2006. Guidelines have been developed, but remain to be implemented., Aim: A population-based study on RC treatment and outcome in Belgium and comparison with recent international benchmarks in order to better define targets that should be reached., Patients and Methods: Anonymous data of 3079 patients with rectal cancer registered in the National Cancer Registry in 1997 and 1998 were analysed. Observed (OS) and relative survival (RS) were compared with figures from nationwide projects and multi-centre studies., Results: The 5-yr OS and RS were 46.6% and 58.5%, respectively. For patients with stage I-III tumours 5-yr OS was 57.1% and 5-yr RS 70.1%. Adjuvant or neo-adjuvant treatment was given in 54.8% stage II-III patients who were < 70 years old. There were marked differences between the provinces in the use of radiotherapy for stage II-III patients and in 5-yr RS for all stages. In stage IV, the median OS was 13 months and the 2-yr OS was 28%. Comparison with recent multi-centre trials indicates significant potential benefits from the PROCARE project: an absolute increase of the 5-yr OS by 10 to 20% after chemoradiotherapy and TME in stage II-III patients 75 years old or less, a 7-month increase of the median OS and an absolute 15% increase of the 2-yr OS in unresectable stage IV patients with combined chemotherapy., Conclusion: Significant improvement seems to be achievable. Implementation of the PROCARE guidelines with quality assurance through prospective registration in a specific database, however, is a crucial prerequisite for credible audit of performance and feedback to individual teams.

Purpose: To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM)., Methods: In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months., Results: Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P < 0.0001). Healing time was shorter after PPH (P < 0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P < 0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM., Conclusions: Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haemorrhoidal disease, needing further surgery.

Anal fistulae do not heal spontaneously without surgery. Knowledge of anorectal anatomy and function, and diligent examination frequently requiring anaesthesia are prerequisites for adequate assessment, classification and treatment of the pathology. Fistulography, endoanal ultrasound and MRI of the anorectum may have additional diagnostic value with therapeutic impact in complex and recurrent fistulae. Parks' classification is most useful because it is the best guide for surgical therapy. In the modern treatment of trans- or suprasphincteric fistula in ano fast or slow division of any part of the striated perianal musculature is to be avoided in order to prevent anal incontinence.

This paper provides some basic insights in economic evaluation and costing methodology by means of illustrations in the field of laparoscopic surgery. Some general methodological aspects are discussed, as well as their impact on the calculation of both societal and hospital costs of medical interventions. First, Health Care Technology Assessment is described, and several techniques of economic evaluation in health care are situated in this area. Two fundamental concepts in costing analysis are discussed : opportunity costs and marginal (or incremental) analysis. Furthermore, it is argued that in designing an economic analysis, sufficient attention should be given to delineating the alternative treatment options and to determining the perspective from which the study is performed (patient, hospital, insurer, society,...). Subsequently, it is argued that all price and wage data for activities performed within a certain period should apply to the same time period. Finally, in order to facilitate overview, re-calculation and interpretation of cost data, it is advised to distinguish fixed from variable costs. Different categories of societal costs are described, as well as a number of methodologies for their evaluation. In calculating hospital costs, the costs of all different resources used (e.g. buildings, equipment, staff, materials) must be identified precisely. The issues of annuitising initial investment expenses, calculating operating and maintenance costs, and allocating labour and overhead costs are discussed. Finally, it is argued that, in all studies, it should be investigated whether the results of the economic analysis are robust to the models' assumptions, by means of sensitivity analysis. This paper provides a practical toolkit for medical doctors, to allow a correct understanding and critical analysis of economic literature in the field of laparoscopic surgery.

Two groups of patients referred for suspicion of acute appendicitis were compared to evaluate the accuracy of preoperative ultrasonography (US) and surgical decision-making. In one retrospective study, US was performed by trainees using a 3.5 MHz probe (219 patients). In the second prospective study, US was performed by a resident radiologist using a 5 MHz probe (144 patients). US accuracy rose from 65% to 90%, especially due to an improved negative predictive value (from 52% to 92%). The positive predictive value of US was 89%. The sonographically adjusted clinical decision to operate was correct in 85%. Thus, all patients with positive US should be operated. In contrast, clinical judgment must prevail in case of negative US findings in order to prevent surgical delay in about 11%. The negative laparotomy rate decreased by 5% only. This is probably due to the limited influence of negative US findings on surgical decision. US is to be recommended in all patients suspected for acute appendicitis when performed with an appropriate probe by an experienced ultrasonographist. However, it may not, on it self, reduce the rate of unnecessary operative procedures.

The presence of intraluminal viable exfoliated tumour cells has been demonstrated in patients with colorectal cancer. Several non-randomised studies found a significant reduction of the recurrence rate after the intraoperative luminal instillation of cytotoxic agents, as compared with "historical" patient series. Antiseptic solutions, e.g. sodium hypochlorite and povidone-iodine, were reported to be "cancericidal" for exfoliated cancer cells in vitro. A survey held among Belgian surgeons practising colorectal cancer surgery revealed that 78% of them never use any agent during surgery. Only a minority performs pre-resectional luminal instillation-mostly to treat the distal (low) anastomotic level: 14% in patients with rectal cancer and 7% in patients with colon cancer. About 8% of the surgeons only perform peritoneal/pelvic lavage at the end of the procedure. This is in strong contrast with surgical practice in the UK. It seems reasonable to advocate intra-operative pre-resectional bowel washouts with cytotoxic agents besides other measures to avoid recurrence, e.g. the no touch isolation technique with early division of the vascular supply, wide excision of the mesenterium, avoidance of iatrogenic tumour perforation, "en bloc" resection if adjacent organs are invaded, adjuvant radio- and chemotherapy.

The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.

Local excision has to be classified as either indeterminate or non curative from a surgical oncological point of view. It seems to be an acceptable procedure for well differentiated, exophytic/polypoid pT1 lesions of less than 3 cm in diameter, providing the resection margins are tumour-free. For all other lesions radical surgery is to be preferred, unless the patient is unfit for major surgery or refuses an eventual permanent colostomy. Complete local excision followed by radiation therapy may become a valuable alternative for well differentiated, small pT2 lesions, but results are too preliminary. If radical surgery is indicated, the distal clearance margin (to be measured in the fresh, unstretched specimen) may be reduced to 2 cm if taking more distal tissue would jeopardise the anal sphincter. The mesorectum should be completely cleared in patients with low- or mid-rectal cancer. A benefit of excision of the internal iliac nodes in rectal cancer below the peritoneal reflection has not been demonstrated. Low anterior resection is the operation of choice for carcinoma with its lower border above 8 cm from the anal verge. Complete, restorative rectum excision with colo-anal anastomosis (CAA) is the option for tumours with their lower border between 6 and 8 cm from the anal verge if an acceptable margin of distal clearance is obtained. Rectal cancer with its distal border below 6 cm usually requires abdominoperineal rectum excision, although restorative proctectomy with CAA may be a valuable alternative in selected patients with small, well or moderately differentiated tumours.

Patients presenting diffuse, advanced, established peritonitis due to free perforation of the colon, in whom an adequate abdominal debridement cannot be obtained in one operative session were selected. We report results of the planned relaparotomy approach in 44 patients as compared with an historical series of 9 analogous patients treated by on demand exploratory relaparotomies. Planned relaparotomies were performed every 2 days until the abdominal cavity became macroscopically clean. This approach significantly reduced both the incidence of multiple organ failure and the mortality rate (31%) as compared with the regimen of on demand relaparotomy. The mortality rate in the planned relaparotomy group is related to the age of the patient and to the nature of peritonitis. Faecal peritonitis carries a higher mortality rate than purulent peritonitis. The mortality rates of severe postoperative peritonitis and advanced primary peritonitis were not significantly different. Surgery for severe, diffuse peritonitis has to be prompt, moderately aggressive and repeated if necessary. Therefore, planned relaparotomies have a place in the treatment of selected patients presenting diffuse, advanced, established peritonitis.

The recurrence rate after highly selective vagotomy was evaluated in patients with chronic duodenal ulcer disease presenting non-refractory (64 cases) or refractory ulcers (41 cases) followed for 1 to 8 years postoperatively. Refractoriness was considered when an ulcer remained symptomatic and was not healed at endoscopy after 8 weeks (3 cases) or 12 weeks (30 cases) of appropriate treatment with cimetidine, or when it recurred during maintenance therapy and did not heal after adapted treatment (8 cases). The cumulative 5 year-recurrence rate was 28.7% in refractory ulcers, in contrast with 9.3% in non-refractory ulcers (p less than 0.05). The early and constantly increased risk of recurrences in the refractory ulcer group could not be explained by factors related to surgeon or technique, nor by differing patient characteristics, including sex, age at the first ulcer episode, duration of the preoperative ulcer disease, familial ulcer history, prior ulcer complications, use or abuse of anti-inflammatory drugs, caffeine or alcohol, smoking habits and occupational state. It is concluded that highly selective vagotomy can not be considered a surgical procedure of choice in patients with refractory duodenal ulcers as there are valuable alternatives.

106 patients had a partial gastrectomy for a benign gastric ulcer. 63 of them got a long-term follow-up. The mean follow-up is 127 months. The mortality rate of the emergency operation is 20%. For the elective operation the mortality rate is 0%. More than 90% of the patients have no complaints after a long time. Following a Billroth I operation most patients feel better initially but later there is no difference at all. The frequency of the ulcer recurrence following a B I is higher than following a B II, but it is lower than after another operation (resp. 5.8% and 2.2%). For these reasons we propose a partial gastrectomy for a benign gastric ulcer in elective circumstances. To prevent alkaline biliary reflux gastritis a 2/3 distal gastrectomy with selective vagotomy and Roux-in-Y anastomosis has to become a routine operation. In emergency circumstances a partial gastrectomy is not indicated because of the high mortality rate.

Thirteen cases of intestinal atresia are described: 9 jejunal and 4 ileal. The duration of pregnancy was significantly shorter and the birthweight significantly lower in jejunal than in ileal atresia. The proximal intestine was strongly dilated in 8/9 cases with jejunal atresia. This group also contains several complex and extended varieties of atresia. The postoperative mortality was 8%. Gastrointestinal functional disturbances occurred only in the group treated for jejunal atresia. These disturbances were temporary and occurred postoperatively in 2 cases but reoperation was mandatory in another 2 cases, once without functional success. There were no problems in the other cases. Ileal atresia is easy to treat and the result is always good. In contrast, the situation is much more challenging in cases of jejunal atresia: prematurity, higher incidence of complex and extended gastrointestinal malformations, impossibility to resect the dilated proximal segment, presence of a long under-developed distal segment. No problems have been observed after construction of a double stoma and restoration of the intestinal continuity. However a proximal stoma leads to important fluid and electrolyte losses, necessitating total parenteral nutrition. Functional gastrointestinal disturbances are frequently observed after end-to-side anastomosis in Y with mucous fistula. An end-to-end anastomosis can be combined with enteroplasty of the proximal distended bowel segment, eventually including the duodenum. Although the enteroplasty technique is an important progress in the treatment of neonates with extended types of jejunal atresia, transit problems cannot always be prevented by this procedure.

Benign neoplasms of the stomach lead to atypical symptoms. Radiological and endoscopic investigations are always recommended. Our surgical experience with 11 epithelial and 26 mesenchymal benign neoplasms is discussed. A local excision could be carried out in 24 patients, of whom 4 developed postoperative complications and one deceased. Ten cases required a partial and 3 cases a total gastrectomy. This was mainly due to the localisation or the extent of the lesions. One surgical complication occurred and one patient died. Relapse was never observed in the long-term (i.e. 6 years) follow-up of 29 patients. Nonetheless, a yearly radiological or endoscopical control is advocated since hyperplastic polyps can relapse as exaggerated healing of an ulcer, and because especially leiomyomas, neurilemmomas en lipomas carry a substantial risk of malignant degeneration.

Evaluation of anorectal function in faecal incontinence. In cases presenting faecal incontinence, an etiological diagnosis should be based on history, clinical examination, anuscopy and rectoscopy. This diagnosis should be confirmed or contradicted by the results of objective investigations, especially manometry, myography and radiology. In the absence of anorectal anatomical defects, a functional cause of incontinence has to be found: megarectum with pseudo-incontinence, psychogenic encopresis, lesions of the nervous system, pudendal neuropathy. In the presence of obvious anatomical defects, the function of all components of the anorectal continence apparatus has to be evaluated; in this way, it will be possible to objectivate the results of conservative or surgical treatment by repetition of the technical investigations. In practice, a complete functional evaluation of the anorectum has to be performed in patients in whom the results of previous therapy remain unsatisfactory.