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Background: This dissertation is composed of five individual studies of the stapled haemorrhoidopexy operation. The operation was launched to an international audience in 1998 by the Italian surgeon Antonio Longo. In conventional surgery the prolapsed piles are excised from the anodermal part of the prolapse up through the anal canal into the lower rectal mucosa where the pile is divided with diathermy or suture ligated and excised. It leaves open wounds throughout the anal canal. These wounds can be very painful, especially at defecation, and will take from three to six weeks to heal. In the stapled haemorrhoidopexy operation symptomatic haemorrhoids are seen as a disease of anodermal, haemorrhoidal and rectal mucosal prolapse of varying degree. The main component of the prolapse is the redundancy of rectal mucosa. By pushing back the prolapse into the anal canal followed by excision of the mucosal redundancy above the anal canal with a circular stapler devise a mucosal anastomosis is fashioned. This anastomosis is situated immediately above the haemorrhoids and will attach them to the rectal muscular wall to prevent further prolapse. The operation is associated with substantially less pain and a quicker recovery.Methods: For the five studies, a total of 334 patients were operated for haemorrhoidal prolapse. The first operations were performed in February 1998. All patients were assessed preoperatively and postoperatively with the same set of protocols as follows. The symptoms of haemorrhoids were scored with a questionnaire to patients to obtain their independent statements of the frequency of each of five cardinal symptoms: pain, bleeding, pruritus, soiling and prolapse in need of manual reduction. A diary was used by patients to report daily pain scores, use of pain medication and speed of recovery within the first 14 postoperative days. The surgeon rated the deranged anal anatomy before and after surgery. We also developed an algorithm based on the patients’ statement of digital reduction of prolapse (grade 3) and the surgeon’s assessment of lesser prolapse at proctoscopy (grade 2). Absence of prolapse was grade 1. The surgeon also provided statements about the conduct of the operation and rated the technical complexity. The information, for all patients, was entered into an electronic data base.Results: One registry based study and one prospective randomised controlled trial assessed the advantage of performing the operation under perianal local anaesthetic block. The postoperative pain and surgical outcome was independent of the type of anaesthesia. No operation under local block had to be converted to general anaesthesia. Anodermal prolapse is seen in 70 percent of the patients. In a registry-based study we found that excision of the anodermal folds did not increase the postoperative pain provided the excision stopped at the anal verge. In 270 patients with precise preoperative and postoperative classification we found that the symptomatic load was identical for grades 2 and 3. The symptoms were independent of the anodermal prolapse. The symptoms were greatly reduced when the operation turned out grade 1 prolapse. The long-term result was assessed in 153 patients operated 1 year to 6 years previously. The need for early re-intervention was 6.2 percent representing technical error to reduce the prolapse. At the final evaluation 12 patients (8.2 percent) complained of a mucoanal prolapse in need of digital reduction. The mean symptom burden had been reduced from 8.1 to 2.5 points but 17 percent had at least one cardinal symptom with a weekly frequency.Conclusions: Stapled haemorrhoidopexy should be performed as day surgery under local anaesthesia. Any remaining anodermal prolapse should be excised. The optimal long-term outcome is grade 1A or 1B with low symptom score. There was an 87 percent chance of cure of the prolapse with the first haemorrhoidopexy. About half the failures were insufficient primary surgery and half a relapse of the prolapse.

Background An audit of all patients with rectal cancer in Sweden was launched in 1995. This is the first report from the Swedish Rectal Cancer Registry (SRCR). Methods Between 1995 and 2003, 13 434 patients treated for adenocarcinoma of the rectum were registered with the SRCR; there were approximately 1500 new patients annually. Results Approximately half had an anterior resection, a quarter an abdominoperineal resection and 15 per cent a Hartmann's procedure. The median 30-day postoperative mortality rate was 2·4 per cent and the overall postoperative morbidity rate was 35·0 per cent. The 5-year cancer-specific survival rate was 62·3 per cent. The 5-year relative survival rate was 70·1 per cent after anterior resection, 59·8 per cent after abdominoperineal resection and 39·8 per cent after a Hartmann's procedure. The crude 5-year local recurrence rate was 9·5 per cent overall, 6·1 per cent after preoperative radiotherapy and 11·4 per cent after surgery alone. For 3868 patients who had a locally curative procedure the local recurrence rate was 7·4 per cent overall, 5·9 per cent for those who had radiotherapy and 10·2 per cent for those who did not. The local recurrence rate was 2·9 per cent (28 of 968) for stage I disease, 7·9 per cent (112 of 1418) for stage II, 13·9 per cent (188 of 1357) for stage III and 8·5 per cent (45 of 532) for stage IV. Conclusion These good population-based results are due, in part, to the nationwide prospective quality assurance registration.

Background Colonic pouch anastomosis after restorative rectal excision obviates much of the early dysfunction which is commonly experienced with the traditional straight coloanal anastomosis. A disadvantage with colonic pouch reconstruction, however, appears to be impaired evacuation. Methods Distal bowel function was investigated in 30 patients with a colonic J pouch anastomosis at 1 year after surgery and in 39 control subjects. Results While the degree of urgency and incontinence were similar, the patients with a pouch experienced more difficult evacuation. The maximum volume of the pouch (median 235 ml) and rectum (221 ml) was similar, but the rectum was more compliant (3.5 versus 2.6 ml per cmH 2 O, P

The relationships between intraoperative endoscopic findings, exterior bowel wall changes and transmural histopathology were investigated in 23 patients with Crohn's disease (24 resections). Villous atrophy and leucocyte infiltration of the epithelium, lamina propria and submucosa were common in intestine without endoscopic lesions. Minor endoscopic ulcers were associated with leucocyte infiltration, ulcers and pyloric metaplasia, and large endoscopic ulcers and stricture with severe transmural inflammation, fibrosis and fissures. In ileal Crohn's disease (19 resections), correlation was close between endoscopic stage and histopathology (rs = 0·77, P

The management of 115 patients with complete neoplastic obstruction of the colon was studied retrospectively. Primary resection was carried out in 40 patients, 22 with right-sided and 18 with left-sided tumours. Staged resection was planned in 48 patients and actually performed in 40. Creation of a stoma only was carried out in 25 patients because of advanced disease. There were no differences between primary and staged resection regarding the patients' general condition, concurrent disease, tumour stage according to Dukes' classification, postoperative complications, or mortality. The postoperative mortality rate was 10 per cent after primary and 15 per cent after staged resection (P not significant). The median hospital stay was 18 and 45 days, respectively. The 5-year survival rate was 38 per cent after primary and 29 per cent after staged resection. All primary resections but one were performed by qualified surgeons, while trainees created stomas as emergency treatment. The similarity in outcome suggests that in future this condition should, where possible, be treated by primary resection, by surgeons experienced in colorectal operations.

Nineteen patients with symptomatic anastomotic leakage after anterior resection were compared with 19 without leakage. The two groups were closely matched according to age, sex, height of anastomosis and follow-up. No patient had any sign of anastomotic stricture or neoplastic recurrence at the time of the study. After a median of 30 (range 12–87) months there was no difference in sphincter function as measured by manometry. Neorectaf volume at distension pressures of 40 and 50 cmH2O and compliance at sensation of filling, urge to defaecate and maximum tolerated volume were significantly reduced in patients with leakage. This reduction in neorectal reservoir function was reflected in impaired anorectal function, measured by a combination of: (1) frequency of bowel movements; (2) degree of urgency; (3) incontinence score; and (4) degree of impaired evacuation. Long-term functional outcome may be impaired by anastomotic leakage.

Patients with a preoperative diagnosis of acute cholecystitis were prospectively allocated to treatment with early cholecystectomy (ES) within 7 days of the onset of symptoms, or initial conservative treatment followed by delayed elective surgery (DS). Patients whose symptoms required emergency operation, patients older than 75 years and patients with pancreatitis were excluded from the trial but were followed up. During the study period 402 patients with acute cholecystitis were admitted, 101 fell into the ES group and 91 into the DS group. The conservative regimen had to be interrupted in 15 patients (13·8 per cent) because their clinical status deteriorated and 13 patients (11·9 per cent) in the DS group did not return for planned elective surgery. One patient in the DS group died. There was no difference in the frequency of intra- and postoperative complications between the 2 study groups, the incidence of bacterial complications being markedly low, especially in the ES group. The ES group had a moderate but significantly greater intraoperative blood loss. Hospital stay was almost 1 week shorter in the ES group and insurance payment for loss of working capacity was also shorter in the ES group. These results indicate that early cholecystectomy is the treatment of choice in acute cholecystitis in patients aged 75 years and under.

Parastomal hernia is a common late complication of enterostomy, especially colostomy, and sometimes requires surgical treatment. A possible contributory factor, location of the stoma in relation to the rectus abdominis muscle, was studied by examination of 130 patients with permanent intestinal stoma. The bowel had been brought out through the rectus abdominis muscle in 107 patients and lateral to it in 23 patients. The respective prevalence of parastomal hernia in these groups was 2·8 per cent and 21·6 per cent. The highly significant difference indicates that enterostomy should be constructed through the rectus abdominis muscle, not lateral to it.

Summary The influence of bowel resection for Crohn's disease on the frequency of arthralgia and perianal manifestations was evaluated in a follow-up study of 82 patients. Arthralgia and perianal manifestations were analysed according to two separate periods: the preoperative duration of disease (4·2±3·2 years) and the postoperative duration (4·3±2·6 years). In patients operated on more than once, the time before the first and after the latest operation was included in the study. At the time of the follow-up, 19 patients suffered from recurrent disease. The frequency of arthralgia did not change after resection irrespective of whether or not there was recurrence. In patients without recurrence, however, perianal manifestations diminished after resection (P < 0·05). In the postoperative period only 10 per cent of those without recurrence suffered from perianal lesions compared with 47 per cent of those with recurrence (P < 0·001). If perianal lesions were in existence preoperatively, they healed spontaneously in 80 per cent of the patients without recurrence, but were still active among those with recurrence (P < 0·001). Our results indicate that the perianal manifestations are closely connected to the inflammatory process in the intestine. On the other hand, the arthralgia seems to be independent of the inflammatory process of the bowel and may be related to a general defect of the gastrointestinal mucosa in Crohn's disease.

Sixty-seven patients with Crohn's disease undergoing 81 resections followed by a restorative procedure were reviewed to evaluate the influence of microscopic disease at the margin of resection on the recurrence rate. The average follow-up after resection was 5·6 + 2·8 years. The resectional margins were classified into three groups depending on the microscopic appearance of the most involved margin. Recurrent disease developed in 36 per cent of the resections without microscopic evidence of Crohn's disease, while 38 per cent of the resections with signs of Crohn's disease developed a clinical recurrence. The recurrence rate increased with the follow-up time, but was independent of microscopical disease at the resectional margins. Therefore we recommend restricted resection of macroscopically diseased bowel. Microscopical involvement does not seem to increase the recurrence rate.

Nine local recurrences have been diagnosed in 38 patients with carcinoma of the rectum operated on with anterior resection using the EEA-stapling instrument. The characteristics of these recurrences have been compared with those of other authors, currently a total of 27 recurrences. The presence of a locally advanced growth with extramural spread, a distal location and a short margin of clearance seems to increase the risk of local recurrence, with often distressing symptoms. It is proposed that even if the EEA-stapler offers technical possibilities for anterior resection in these growths, this operation should be restricted to less advanced tumours.