Search

In the absence of an internationally agreed classification of haemorrhoids, evaluation of the ever increasing number of therapeutic options available is impossible. A new classification is proposed which relates symptoms to our knowledge of haemorrhoidal development, the use of which should provide a more accurate way of comparing treatments and in the evaluation of new techniques. The evidence for such a classification is presented in detail. [ABSTRACT FROM AUTHOR]

Background Internal anal sphincter tone depends on the intrinsic myogenic properties of smooth muscle and external neural influences, specifically a continuous sympathetic input. Reduction of maximum resting anal canal pressure (MRP) increases the vascularity of ischaemic chronic anal fissures and promotes healing. Methods Ten patients with chronic anal fissures (median age 35.5 (28-65) years) and 10 healthy volunteers (median age 28 (21-38) years) were administered 20 mg indoramin (α[sub 1]-antagonist) or 4 mg salbutamol (&beta[sub 2]-agonist) orally in a doubleblinded manner. MRP, pulse, and blood pressure were measured prior to and at hourly intervals until 3 h after administration. Results Patients with chronic anal fissures had a significantly higher MRP compared with volunteers (P < 0.05, MannWhitney U-test). In each group there was a significant reduction in MRP at 1, 2 and 3 h (P < 0.05, Wilcoxon signed ranks test). Indoramin and salbutamol demonstrated no significant difference in effect when comparing reduction of MRP in patients and volunteers (Mann-Whitney U-test). The reduction in patients' MRP at 3 h was comparable to that after lateral sphincterotomy. Tremors were noted with salbutamol in four volunteers, and five patients. Three patients complained of light-headedness with indoramin without a significant change in diastolic blood pressure. The reduction in MRP in subjects who took indoramin did not correlate with a reduction in diastolic blood pressure (Pearson correlation coefficient, r = 0. 166, P = NS). Conclusion Oral indoramin causes a sustained reduction in MRP, without serious side effects, and may have a beneficial role in the treatment of anal fissures. (MRP - maximum resting anal canal pressure). [ABSTRACT FROM AUTHOR]

The article offers information on studies related to colorectal diseases published in the previous issues of various journals. A paper from the "Diseases of the Colon and Rectum" talks about the Moloney Antegrade Continent Enema technique used for treating patients with severe defacaetory disorders. A paper from "Archives of Surgery" talks about the risk factors for the development of abdominal abscess formation after perforated appendicitis in children. Other papers are also cited.

Aim This manuscript provides the introduction and detailed methodology used in subsequent reviews to assess the outcomes of surgical interventions with the primary intent of treating chronic constipation in adults and to develop recommendations for practice. Method PRISMA guidance was adhered to throughout. A literature search was performed in public databases between January 1960 and February 2016. Studies that fulfilled strictly-defined PICOS (patients, interventions, controls, outcome, and study design) criteria were included. The process involved two groups of participants: (i): 'a clinical guidance group' of 18 UK experts (including junior support) who performed the systematic reviews and produced summary evidence statements ( SES) based strictly on data synthesis in each review. The same group then produced prototype graded practice recommendations ( GPRs) based on coalescence of SES and expert opinion; (ii): a European Consensus group of 18 ESCP (European Society of Coloproctology) nominated experts from nine European countries evaluated the appropriateness of each prototype GPR based on published RAND/ UCLA methodology. Results An overview of the search results is provided in this manuscript. A total of 156 studies from 307 full text articles (from 2551 initially screened records) were included, providing data on procedures characterized by: (i) colonic resection ( n = 40); (ii) rectal suspension ( n = 18); (iii) rectal wall excision ( n = 44); (iv) rectovaginal septum reinforcement ( n = 47); (v) sacral nerve stimulation ( n = 7). The overall quality of evidence was poor with 113/156 (72.4%) studies providing only Oxford level IV evidence. The best evidence was extracted for rectal excisional procedures, where the majority of studies were Oxford level I or II. The five subsequent reviews provide a total of 99 SES (reflecting perioperative variables, efficacy, harms and prognostic variables) that contributed to 100 prototype GPRs covering patient selection, procedural considerations and patient counselling. The final manuscript details the 85/100 GPRs that were deemed appropriate by European Consensus (remaining 15 were all uncertain) and future research recommendations. Conclusion This manuscript and the following 6 papers suggest that the evidence base for surgical management of chronic constipation is currently poor although some expert consensus exists on best practice. Further studies are required to inform future commissioning of treatments and of research funding. [ABSTRACT FROM AUTHOR]

Aim This manuscript forms the final of seven that address the surgical management of chronic constipation ( CC) in adults. The content coalesces results from the five systematic reviews that precede it and of the European Consensus process to derive graded practice recommendations ( GPR). Methods Summary of review data, development of GPR and future research recommendations as outlined in detail in the 'introduction and methods' paper. Results The overall quality of data in the five reviews was poor with 113/156(72.4%) of included studies providing only level IV evidence and only four included level I RCTs. Coalescence of data from the five procedural classes revealed that few firm conclusions could be drawn regarding procedural choice or patient selection: no single procedure dominated in addressing dynamic structural abnormalities of the anorectum and pelvic floor with each having similar overall efficacy. Of one hundred 'prototype' GPRs developed by the clinical guideline group, 85/100 were deemed 'appropriate' based on the independent scoring of a panel of 18 European experts and use of RAND- UCLA consensus methodology. The remaining 15 were all deemed uncertain. Future research recommendations included some potential RCTs but also a strong emphasis on delivery of large multinational high-quality prospective cohort studies. Conclusion While the evidence base for surgery in CC is poor, the widespread European consensus for GPRs is encouraging. Professional bodies have the opportunity to build on this work by supporting the efforts of their membership to help convert the documented recommendations into clinical guidelines. [ABSTRACT FROM AUTHOR]

The article offers information on various studies and reports related to colorectal diseases. It mentions a study that compares Hispanics and Caucasians with inflammatory bowel disease (IBD) and Crohn's disease (CD). One study found that a high-protein, low-carbohydrate and low-fiber diet may increase the risk of colonic diseases. A paper on how to manage fungating wounds is also discussed.

Aim Permacol™ collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial. Method Patients ( N = 30) with anal fistula presenting to 10 European academic surgical units were treated with a sphincter-preserving technique using Permacol paste. Fistula healing was assessed at 1, 3, 6 and 12 months after treatment, with the primary end-point of fistula healing at 6 months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up. Results Of the 28 patients with data at 6 months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol paste was similar for intersphincteric to transsphincteric fistulae and primary or recurrent fistulae. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation. Conclusion Permacol paste is shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects. [ABSTRACT FROM AUTHOR]

The article discusses several studies related to coloproctology. The "Journal of Clinical Diagnosis and Research" featured a paper that discussed the important role of lateral internal anal sphincterotomy (LIAS) in the treatment of chronic anal fissure. A study published in the journal "BMC Infectious Diseases" found the presence of necrotizing fasciitis, caused by Haemophilus influenzae type b, in patients taking Bevacizumab to treat rectal cancer.

The article presents a list of papers focusing on the various ways to address different kinds of colorectal diseases. They include the "European Journal of Nutrition" which discusses the significance of utilizing a hand dynamometer to evaluate malnutrition of patients in hospitals, "Diseases of the Colon and Rectum" concerning the postoperative effect of tissue welding device and vessel sealing device, and "Digestive Diseases and Sciences" which focuses on the treatment of fistula-in-ano.

Aim The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research. Method MEDLINE, EMBASE and Pub Med were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient. Results Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence. Conclusion Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research. [ABSTRACT FROM AUTHOR]

Aim Intra-abdominal desmoid disease is one of the most common extra-intestinal manifestations of familial adenomatous polyposis. Small bowel obstruction occurs frequently in affected patients and is notoriously difficult to treat. The aim of this study was to review the management and outcome of desmoid-related small bowel obstruction. Method This was a retrospective, descriptive study of patients with familial adenomatous polyposis and intra-abdominal desmoid disease who developed small bowel obstruction. Demographic data and data concerning the presentation, diagnosis and treatment of the bowel obstructions were abstracted from the polyposis database or patients' records. Patients with obstruction unrelated to desmoid disease were excluded. Results There were 47 patients (30 women and 17 men). Median age at first bowel obstruction was 24.2 (interquartile range 19.2-34.2) years. The median time from index surgery to first bowel obstruction was 4.1 (interquartile range 1.5-9.0) years. Twenty-two patients had a colectomy and ileorectal anastomosis and 21 a proctocolectomy and ileoanal pouch. Obstruction was treated medically in 29% of cases and surgically in 69%. Thirteen patients had total parental nutrition. Thirty (63.8%) had a second episode of small bowel obstruction at a mean of 5.3 years after the first, 50% of which were treated medically. Eighteen (37.5%) patients had more than two episodes of bowel obstruction. There were 118 operations, including lysis of adhesions (29), small bowel resection (14), bypass (12), ileostomy (12), desmoid excision (9) and stricturoplasty (2). Conclusion Desmoid-related small bowel obstruction in familial adenomatous polyposis patients requires multiple surgical strategies to restore a patent gastrointestinal tract. What does this paper add to the literature? This is the only series in the literature specifically addressing small bowel obstruction in patients with familial adenomatous polyposis and intra-abdominal desmoid disease. The data show that small bowel obstruction is common, tends to recur, but can be successfully managed by a combination of medical and well selected surgical treatment. [ABSTRACT FROM AUTHOR]

Aim This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. Method We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included. Results Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy. Conclusion There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy. [ABSTRACT FROM AUTHOR]

Objective The aim of this paper was to analyse the results of treatment of anal fistulas retrospectively. Methods Between 1992 and 2004, 407 patients were operated on for perianal fistula. In the follow-up period, 107 patients were lost, so 300 patients were analysed in the study. The mean follow-up time was 4.2 years. Analysed parameters included: types of surgical procedures in different kinds of fistulas and postoperative complications. Various types of surgical procedures and their effectiveness were described. Late results were assessed taking into account healing time, duration of sick leave, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed according to the Cleveland Clinic Incontinence Score. Results In our study, subcutaneous fistula was diagnosed in 23.3%, inter-sphincteric in 18%, trans-sphincteric in 37.7%, supra-sphincteric in 16% and extra-sphincteric in 5% of patients. Single-tract fistulas were present in 88.7% and multi-tract fistulas were present in 11.3%. Overall, 242 patients had primary fistulas and 58 patients had recurrent fistulas. The most frequently performed procedures were cutting seton (139 patients) and radical fistulectomy (104 patients). Recurrent fistulas developed in 14.3%. Postoperative gas and/or stool incontinence was noticed in 10.7%. The recurrence rate was 5.4% in patients with primary fistula and in 51.7% patients presenting with a recurrent fistula. Gas and stool incontinence developed in 3.7% of patients with primary fistulas and in 39.7% of patients presenting with recurrent fistulas. Recurrence rate was 12% in the patients of single-tract fistulas and 32.4% in the patients of multi-tract fistulas. Postoperative gas and/or stool incontinence occurred in 8.3% of patients of single-tract fistulas and in 29.4% of patients of multi-tract fistulas. Conclusions The complication rate was 10-fold higher in patients presenting with a recurrent fistula than in those with primary fistulas and threefold higher in patients with multi-tract fistulas than in those with single-tract fistulas. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Postoperative ileus (POI) is characterised by delayed gastrointestinal recovery and is common after colorectal surgery. Numerous strategies to optimise POI have been proposed but its management remains an unmet clinical need. This study aimed to characterise the duration and management of gastrointestinal recovery in patients undergoing elective colorectal surgery. Method: A snapshot, prospective, observational study was undertaken between November 2016 and January 2017 at 10 regional hospitals in the United Kingdom. Adult patients undergoing elective colorectal surgery with resection of bowel or reversal of stoma were included. Outcomes included time until return of gastrointestinal function, timing of nasogastric tube (NGT) insertion, uptake of targeted interventions and clinical outcomes. Data were validated for accuracy by independent investigators. Results: 204 patients met the eligibility criteria. The median time for gastrointestinal recovery was 3 days (IQR 2–4); right‐sided resections were associated with longer gastrointestinal recovery than left sided (4 days (2.75–5.25) vs 3 days (2–4); P = 0.002). The rate of NGT insertion was 22.5% at a median time of 4 (4–4.75) days. NGT insertion after vomiting was associated with a higher incidence of bronchopneumonia compared to early placement (13.3% vs 29.0%). Targeted interventions, such as chewing gum (4.4%), selective mu‐receptor antagonists (1.0%) and pro‐kinetic agents (13.7%) were infrequently used. Conclusion: The average time to gastrointestinal recovery after elective colorectal surgery was three days. Late NGT insertion was associated with an increased incidence of bronchopneumonia. The clinical uptake of targeted interventions to improve gastrointestinal recovery was poor. [ABSTRACT FROM AUTHOR]

Background: Sclerotherapy with 3% polidocanol foam is becoming increasingly popular for the treatment of symptomatic I–II or III degree haemorrhoidal disease (HD). However, there are no studies that have reported a follow‐up of more than 1 year. The purpose of this study was to analyse the long‐term outcomes of sclerotherapy with 3% polidocanol foam in the treatment of II–degree HD. Methods: This was an open label, single‐arm, phase 2b trial conducted in 10 tertiary referral centres for HD. A total of 183 patients with II–degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification and unresponsive to medical treatment, were included in the study and underwent sclerotherapy with 3% polidocanol foam. The efficacy was evaluated in terms of bleeding score, haemorrhoidal disease symptom score (HDSS) and short health scale for HD (SHS–HD) score. Successful treatment was defined as the complete absence of bleeding episodes after 7 days (T1) according to the bleeding score. Results: The overall success rate ranged from 95.6% (175/183) at 1 year to 90.2% (165/183) after the final 3 year follow‐up. The recurrence rate, based on the primary outcome, ranged from 12% (15/125) to 28% (35/125). The greatest increase in recurrence (15) was recorded between 12 and 18 months of follow‐up, then another five between 18 and 24 months. Both the HDSS and the SHS score remained statistically significant (p < 0.001) from a median preoperative value of 11 (10–13) and 18 (15–20) to 0 (0–2) and 4 (0–4), respectively. Symptom‐free (HDSS = 0) patients, excluding patients converted to surgery, increased from 55.5% (101/182) at 1 year to 65.1% at 3 years (110/169). There were no intraoperative complications in redo‐sclerotherapy nor additional adverse events (AEs) compared to the first 12 months. Conclusions: Sclerotherapy with 3% polidocanol foam is gradually establishing itself in the treatment of bleeding HD due to its repeatability, safety, convenience in terms of direct and indirect costs with the absence of discomfort for the patient as well as AEs rather than an excellent overall success rate. [ABSTRACT FROM AUTHOR]

The article offers information related to colorectal disease. It says that young patients with acute diverticulitis require urgent surgery during primary admission and hospitalization than older patients. It mentions that the survival of patients who undergo intestinal and multivisceral transplantation are 68% good at one year and 61% at three years.

Aim To assess the outcomes of rectal suspension procedures (forms of rectopexy) in adults with chronic constipation. Method Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level. Results Eighteen articles were identified, providing data on outcomes in 1238 patients. All studies reported only on laparoscopic approaches. Length of procedures ranged between 1.5 to 3.5 h, and length of stay between 4 to 5 days. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 5-15%, with mesh complications accounting for 0.5% of patients overall. No mortality was reported after any procedures in a total of 1044 patients. Although inconsistently reported, good or satisfactory outcome occurred in 83% (74-91%) of patients; 86% (20-97%) of patients reported improvements in constipation after laparoscopic ventral mesh rectopexy (LVMR). About 2-7% of patients developed anatomical recurrence. Patient selection was inconsistently documented. As most common indication, high grade rectal intussusception was corrected in 80-100% of cases after robotic or LVMR. Healing of prolapse-associated solitary rectal ulcer syndrome occurred in around 80% of patients after LVMR. Conclusion Evidence supporting rectal suspension procedures is currently derived from poor quality studies. Methodologically robust trials are needed to inform future clinical decision making. [ABSTRACT FROM AUTHOR]

The necessity, timing and benefits of follow-up after rectal cancer surgery remain controversial, with two years traditionally considered adequate to detect most local recurrences. This unit has a policy of lifetime follow-up, and this paper investigates, at 23 years, the value of prolonged surveillance.Six hundred and sixty consecutive patients undergoing surgery for rectal cancer were prospectively followed-up between 1978 and 2002, and local or systemic recurrence recorded. This analysis was performed on the 509/660 (76%) patients who underwent potentially curative surgery.Total mesorectal excision (TME) was performed in 422/509 (83%) patients, mesorectal transection in 78 (15%), and local excision in 9 (2%). Follow-up ranged from 1 to 23 years (mean = 9.7). Seven (1.4%) patients had local recurrence alone, 11 (2.2%) local plus systemic, and 86 (17%) systemic recurrence alone. Of the local recurrences 3 (17%) became evident within 1 year, 9 (50%) within 2 years, 16 (89%) within 5 years, and 2 (11%) presented after 5 years, at 5.6 and 5.8 years. Of the systemic recurrences 26 (27%) became evident within 1 year, 57 (59%) within 2 years, 93 (96%) within 5 years, and 4 (4%) presented after 5 years at 5.3, 5.3, 5.4 and 7.9 years.This long-term surveillance of patients undergoing curative surgery for rectal cancer demonstrates that most local and systemic recurrences occur within 5 years. Almost half occurred more than 2 years after surgery. However, those centres wishing to set standards of care, or evaluate current or new therapies in rectal cancer treatment, should be aware that unexpected late recurrences occasionally develop. [ABSTRACT FROM AUTHOR]

The article features a set of abstracts of various research papers presented at the meeting of Royal Society of Medicine, London on November 23, 2003. Some of the papers presented are Sacral nerve stimulation (SNS) for faecal incontinence in the Great Britain; Fatigability of the external anal sphincter in faecal incontinence; Treatment of persistent perineal sinus with pedicled flap: experience of a single colorectal surgeon etc. SNS is safe effective in the medium to long term for treatment of faecal incontinence when conservative treatment has failed.

The article discusses several articles published in different journals. Topics discussed include surgery alone in stage II colon cancer and randomised-controlled trial of 1-year adjuvant chemotherapy with oral tegafur-uracil (UFT), use of primary anastomosis with diverting ileostomy in patients with acute diverticulitis requiring urgent surgery and appetite for exenterating their patients for localised locally advanced rectal cancer.

The article discusses the various cases of inflammatory bowel diseases (IBD) based on medical research studies. Topics discussed include providing the best treatment procedures for anal fistula, treatment options for severe cases of Endometriosis and colectomy, along with a brief about rectal prolapse surgery.

An introduction to articles in this issue is presented including surgical practice relating to the treatment of chronic constipation, colonic resection and a synopsis of graded practice recommendations.

The article discusses the function of Gemellus which notes that the need for surgery to correct an anastomotic leak was the determining factor in a poorer outcome from cancer. The Gemellus affirmed that by using staged operative procedures the deeper fistulae were all healed in the end with no patient at all being incontinent.

Aim A systematic review of the literature was performed to establish evidence to support the practice that in the presence of a colonoscopically diagnosed colorectal cancer immediate endoscopic excision of synchronous polyps should not be performed due to the risk of malignant cell implantation at the polypectomy site. Method A systematic literature search was performed using Medline, Embase and the Cochrane Central Register of Controlled Trials to identify studies comparing the rate of implantation of colorectal cancer cells in normal and damaged colonic mucosa and reports of colorectal cancer cells seeding into sites of damaged mucosa after polypectomy. Results No randomized controlled trials were identified. Three studies involving mammalian models of colonic mucosal damage were included. Pooling relevant results revealed that out of 59 exposed mammals only one developed tumour cell implantation at a site of colonic mucosal damage. This equates to a mammalian in vivo experimental risk of malignant cell implantation of 1.6%. Conclusion The topic of colorectal cancer seeding following endoscopic procedures has received little attention. This review suggests that in the presence of a proximal colonic carcinoma there is a negligible risk of malignant implantation if a more distal polyp is endoscopically excised. [ABSTRACT FROM AUTHOR]

Aim: Guidelines benefit patients and clinicians by distilling evidence into easy‐to‐read recommendations. The literature around the management of haemorrhoids is immense and guidelines are invaluable to improve treatment integrity and patient outcomes. We identified current haemorrhoid guidelines and assessed them for quality and consistency. Methods: A systematic search of the literature from January 2011 to October 2021 was carried out. Guidelines identified were assessed for quality using the AGREE II instrument and for consistency in terms of tabulated treatment recommendations. Results: During this period nine guidelines were identified worldwide. The general quality was poor with only one guideline considered of high enough quality for use. In general, expert selection criteria for guideline development groups were vaguely defined. There were inconsistencies in the interpretation of the published evidence leading to variation in treatment recommendations. Discussion: Fewer, higher quality guidelines, with more consistent results, are needed. Particular attention should be given to defining the selection of experts involved. [ABSTRACT FROM AUTHOR]

Aim: Anismus is a common cause of obstructed defaecation syndrome (ODS). The aim of the present review is to assess the efficacy and safety of puborectalis muscle (PRM) division in the treatment of anismus. Method: PubMed, Scopus, Web of Science and the Cochrane Library were searched for studies that assessed the outcome of PRM division in the treatment of anismus. The main outcome measures were subjective improvement in ODS, decrease in the Wexner constipation score and ODS score, and complications, namely faecal incontinence (FI). Results: Ten studies (204 patients, 63.7% male) were included. The weighted mean rate of initial subjective improvement across randomized trials was 97.6% (95% CI 94%–100%) and across nonrandomized studies it was 63.1 (95% CI 39.3%–87%). The weighted mean rate of 12‐month improvement across randomized trials was 64.9% (95% CI 53.3%–76.4%) and across nonrandomized studies it was 55.9% (95% CI 30.8%–81%). The weighted mean rate of FI across randomized trials was 12.1% (95% CI 4.2%–20%) and across nonrandomized studies it was 10.4% (95% CI 1.6%–19.3%). Male sex and unilateral PRM division were significantly associated with recurrence of symptoms after PRM division. Bilateral PRM division, posterior division, complete division and concomitant sphincterotomy were significantly associated with FI after PRM division. Conclusions: The use of PRM division for treatment of anismus was followed by some initial improvement in ODS symptoms which decreased to <60% 12 months after PRM division. The mean rate of FI after PRM division, namely 10%–12%, is a limitation of the technique. Further well‐designed trials are needed to verify the outcome of PRM division in the treatment of anismus. [ABSTRACT FROM AUTHOR]

The article offers information on several article published in different periodicals on topics including colorectal disease, nonantibiotic treatment of uncomplicated diverticulitis, and repairing of ventral hernias (VHR).

Aim Fistula laser closure (FiLaC™) is a novel sphincter-saving procedure for the treatment of anal fistula. Primary closure of the track is achieved using laser energy emitted by a radial fibre connected to a diode laser. The energy causes shrinkage of the tissue around the radial fibre with the aim being to close the track. This pilot study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula. Method Thirty-five patients with anal fistula underwent the FiLaC™ procedure. They had either a primary or a recurrent trans-sphincteric anal fistula, a previously placed seton or a fistula involving a significant portion of the sphincter with a potential risk of postoperative incontinence on fistulotomy. The surgical procedure consisted of 'sealing' the fistula by laser energy. The primary end-point was cure of the disease and evaluation of morbidity. The secondary end-point was an assessment of the degree of postoperative continence using the Cleveland Clinic Florida ( CCF) Fecal Incontinence Score. Results The median operation time was 20 (6-35) min. No intra-operative complications were reported. Median duration of follow up was 20 (3-36) months. Primary healing was observed in 25 (71.4%) patients. There were eight (23%) failures and two recurrences at 3 and 6 months after the operation. No patient reported incontinence postoperatively. Conclusion The laser FiLaC™ procedure for fistula-in-ano is a safe, relatively simple, minimally invasive, sphincter-saving procedure with a high chance of success. [ABSTRACT FROM AUTHOR]

Aim The treatment of desmoid tumours (DTs) is controversial. Anti-oestrogen therapy has frequently been used, but clear information of its efficacy is lacking. In this systematic review we have undertaken a comprehensive analysis to assess the effectiveness of anti-oestrogen therapy in terms of ability to induce partial or complete regression of DTs. Method A systematic review of articles published in English between January 1983 and December 2009 was carried out according to the RECIST criteria. A literature search was performed on electronic databases including: United States National Library of Medicine (MEDLINE-PubMed), Excerpta Medica (EMBASE), Cochrane Library and Google search engine. Two-hundred articles dealing with DTs were identified but only fourty-one were were selected as appropriate for the study. The chi-square test was used for statistical analysis. Results Data on 168 DTs treated with anti-oestrogen agents, alone or in combination with nonsteroidal anti-inflammatory drugs, were identified with an overall response rate of 51%. There was no difference in response according to the type of DTs or between different anti-oestrogen therapies. Combination with anti-inflammatory drugs did not improve the outcome. Toremifene was sometimes effective in cases resistant to tamoxifen. Response did not seem to be related to oestrogen receptor status. Conclusions Despite potential inaccuracies in the methodology, the results of the review indicate that anti-oestrogen therapy produces some effect in about one half of patients with DTs. Its indication compared with other treatments is discussed. [ABSTRACT FROM AUTHOR]

Information about several papers discussed at a consensus conference on internal medicine is presented. Surgeons expressed their concerns on the safety and efficacy of anal fistula plug for the treatment of anal fistula. The conference featured several surgeons including Herand Abcarian, H. Randolph Bailey, and Bradley J. Champagne.

Aim A modification is described of the J-pouch to facilitate ileoanal anastomosis in the presence of an anal or anovaginal fistula. Method The bowel is divided at the level of the apex of the J-pouch, the distal limb is advanced to project beyond the proximal limb by 3-5 cm. The pouch is constructed by a side-to-side anastomosis to form the H-pouch with a distal ileal segment, which is passed through the anal canal to form an ileoanal anastomosis. Results The modification allows the treatment of anal and rectal disorders not resolvable by a usual J-pouch construction, as in cases where a rectal resection is needed for concomitant fistulation or destruction of the anal mucosa. The functional results are similar to those of the J-pouch, with no added postoperative morbidity. This technique helps to avoid permanent stoma in selected cases. Conclusion The modified pouch is relatively simple to perform and can help the surgeon to address complex anorectal disorders. [ABSTRACT FROM AUTHOR]

The article focuses on Gemellus, an old colonoscopist who has made his contribution on the treatment of anal fissure as well as his other medical related works. It mentions the peri-appendiceal red patch (PARP), in which Gemellus has a great curiosity on whether PARP is the only skip lesion in ulcerative colitis (UC). Meanwhile, it cites the study on patients who underwent a general anaesthetic after fissure surgery which depicts a healing of the fissure without the need to reoperate.

The article offers information on the study regarding the operation for Altemeier's perineal repair of rectal prolapse conducted in Switzerland.

A letter to the editor is presented in response to the article about the efficacy of transanal haemorrhoidal dearterialization treating advanced haemorrhoids that was published in the previous issue.

Aim: Published prognostic scores for metastatic colorectal cancer (mCRC) are based on data from highly selected patient subgroups with specified first‐line treatments and may not be applicable to routine practice. We have therefore developed and validated the metastatic colorectal cancer score (mCCS) to predict overall survival (OS) for patients with mCRC. Method: A total of 1704 patients from the prospective, multicentre cohort study Tumour Registry Colorectal Cancer were separated into learning (n = 796) and validation (n = 908) samples. Using a multivariate Cox regression model, the six‐factor mCCS was established. Results: The six independent prognostic factors for survival are as follows: two or more metastatic sites at the start of first‐line treatment, tumour grading ≥ G3 at primary diagnosis, residual tumour classification ≥ R1/unknown, lymph node ratio (of primary tumour) ≥ 0.4, tumour stage ≥ III/unknown at primary diagnosis and KRAS status mutated/unknown. The mCCS clearly separated the learning sample into three risk groups: zero to two factors (low risk), three factors (intermediate risk) and four to six factors (high risk). The prognostic performance of the mCCS was confirmed in the validation sample and additionally stratified a large sample of patients with known (K)RAS mutation status. Conclusion: The novel prognostic score, mCCS, clearly defines three prognostic groups for OS at start of first‐line therapy. For oncologists, the mCCS represents a simple and easy‐to‐apply tool for routine clinical use, as it is based on objective tumour characteristics and can assist with treatment decision‐making and communication of the prognosis to patients. [ABSTRACT FROM AUTHOR]

Aim: Colorectal cancer (CRC) is diagnosed in approximately 45 000 people annually in the UK, and it is estimated that Lynch syndrome (LS) accounts for 3.1% of these cases. In February 2017, National Institute for Health and Care Excellence (NICE guideline DG27 recommended universal testing of new cases of CRC for mismatch repair (MMR) status. The aim of this study was to implement universal testing for LS in CRC patients in a secondary care setting. Method: We prospectively collected data on consecutive newly diagnosed CRC patients at our centre from November 2016 to August 2018, including evidence of MMR status determined by immunohistochemistry. We recorded clinicopathological data including age at diagnosis, stage, tumour site, reported histological findings and MMR tumour status. Statistical analysis was performed using the chi‐square test and the two‐tailed t‐test for binary and continuous variables, respectively. Results: A cohort of 203 consecutive patients were diagnosed with CRC during this period. Universal MMR testing was performed for the 198 CRC patients in whom a diagnosis of adenocarcinoma was confirmed, with colonoscopic biopsy used as the source material in 68.6% of cases. Twenty‐three CRCs (11.6%) were MMR deficient (dMMR). Most dMMR CRCs (21/23) were early stage tumours (Dukes A or B, P = 0.002). In 39 Dukes B CRCs in patients under 70 years of age, the result of MMR testing influenced decision‐making about personalized treatment with 5‐fluorouracil based chemotherapy. Conclusion: Our results demonstrate that universal testing of all new cases of CRC for features suggestive of LS is feasible and effective in the UK. Our data also indicate the importance of genetic testing and personalized oncological care. [ABSTRACT FROM AUTHOR]

Aim: Recent data have suggested near‐equivalent oncological results when treating early rectal cancer by local excision followed by radio‐ ± chemotherapy rather than salvage radical surgery. The aim of this retrospective study was to assess the use of contact X‐ray brachytherapy within this paradigm. Method: All patients had undergone local excision and were referred to our radiotherapy centre for treatment with contact X‐ray brachytherapy. Postoperative (chemo)radiotherapy was also given in their local hospital in most cases. Variables assessed were local excision method, postoperative therapy received, follow‐up duration, disease‐free survival, salvage surgery and stoma‐free survival. Results: In total, 180 patients with a median age of 70 (range 36–99) years were assessed. Following local excision, pT stages were pT1 = 131 (72%), pT2 = 44 (26%), pT3 = 5 (2%). All patients received contact X‐ray brachytherapy boosting at our centre and, in addition, 110 received chemoradiotherapy and 60 received radiotherapy alone. After a median follow‐up of 36 months (range 6–48), 169 patients (94%) remained free of local recurrence. Of the 11 patients with local recurrence (three isolated nodal), five underwent salvage abdominoperineal excision. Eight patients developed distant disease, of whom five underwent metastasis surgery. At last included follow‐up 173 (96%) patients were free of all disease and 170 (94%) were stoma free. Conclusions: Contact therapy can be offered in addition to external beam radio (±chemo) therapy instead of radical surgery as follow‐on treatment after local excision of early rectal cancer. This combination can provide equivalent outcomes to radical surgery. The added value of contact therapy should be formally assessed in a clinical trial. [ABSTRACT FROM AUTHOR]

Aim: The Renew® anal insert is a recent treatment for patients who suffer from passive faecal incontinence (FI). Our aim was to assess the effectiveness of the insert and patients' satisfaction with it. Method: A retrospective audit of patients who were treated with the Renew® anal insert was undertaken. The St Mark's Incontinence Score was used to evaluate clinical outcome. Renew® size, the number of inserts used per day and per week had also been recorded. Subjective assessment of symptoms, how beneficial Renew® was and how satisfied patients were with the device were all recorded. Major events and side effects were also noted. Results: Thirty patients received Renew® as a treatment for passive incontinence in 2016. The median St Mark's Incontinence Score was 15 (range 7–18) at baseline and 10 (range 2–18) at first follow‐up (P < 0.0001) at a median of 11 (range 8–14) weeks. Eleven (37%) patients used the regular size and 19 (63%) the large size. Patients used an average of 1.67 inserts per day (range 1–3) on an average of 3.58 days per week (1–7). Three patients reported a deterioration in symptoms, seven (23%) had no change and 20 (67%) showed a significant improvement. Six patients (20%) did not like the device while 24 (80%) liked it. Seventeen patients (57%) wanted to continue this treatment in the long term. Conclusion: The Renew® device seems to be an acceptable and effective therapeutic option for passive FI. Further work is needed to compare it with other treatments and establish its position in the treatment pathway. [ABSTRACT FROM AUTHOR]

Aim: Many surgeons consider total proctectomy with ileal pouch–anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients. Methods: A retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal‐pouch anastomosis for J‐pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra‐operative findings, type of surgical intervention and postoperative outcomes. Results: Surgical interventions were performed on eight patients with J‐pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarily anastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow‐up of 36.5 months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred. Discussion: J‐pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J‐pouches being performed, awareness of novel surgical techniques is important. [ABSTRACT FROM AUTHOR]

Aim: In colorectal cancer, ligation of the inferior mesenteric artery (IMA) is a standard surgical approach. In contrast, ligation of the IMA is not mandatory during treatment of diverticular disease. The object of this meta‐analysis was to assess if preservation of the IMA reduces the risk of anastomotic leakage. Method: A search was performed up to August 2018 using the following electronic databases: MEDLINE/PubMed, ISI Web of Knowledge and Scopus. The measures of treatment effect utilized risk ratios for dichotomous variables with calculation of the 95% CI. Data analysis was performed using the meta‐analysis software Review Manager 5.3. Results: Eight studies met the inclusion criteria and were included in the meta‐analysis: two randomized controlled trials (RCTs) and six non‐RCTs with 2190 patients (IMA preservation 1353, ligation 837). The rate of anastomotic leakage was higher in the IMA ligation group (6%) than the IMA preservation group (2.4%), but this difference was not statistically significant [risk ratio (RR) 0.59, 95% CI 0.26–1.33, I2 = 55%]. The conversion to laparotomy was significantly lower in the IMA ligation group (5.1%) than in the IMA preservation group (9%) (RR 1.74, 95% CI 1.14–2.65, I2 = 0%). Regarding the other outcomes (anastomotic bleeding, bowel injury and splenic damage), no significant differences between the two techniques were observed. Conclusion: This meta‐analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate when comparing IMA preservation with IMA ligation. Thus, to date there is insufficient evidence to recommend the IMA‐preserving technique as mandatory in resection for left‐sided colonic diverticular disease. [ABSTRACT FROM AUTHOR]

Aim: Rectal prolapse (RP) is usually associated with elderly women and is well recognized as having a detrimental effect on quality of life. A number of surgical procedures for RP are available, but morbidity and mortality are substantial. The Gant–Miwa–Thiersch procedure (GMT) has been frequently used for RP in Japan. However, as GMT has a high recurrence rate it is not widely used elsewhere. The aim of this study was to evaluate a modified version of GMT (mGMT) in comparison with other procedures. Method: mGMT was performed under spinal or local anaesthesia in 187 patients with RP. No normal mucosa was left between the tags and lateral wounds were created in the Thiersch procedure. Morbidity, mortality and recurrence rates were recorded. Results: No serious postoperative complications and no operative deaths occurred after mGMT. Eight per cent of patients suffered from infection of the strings. The overall recurrence rate after mGMT was 7.5% with a median follow‐up period of 13.8 years. Conclusion: On the basis of these results, we consider that mGMT has a number of advantages: it is minimally invasive, does not require general anaesthesia, is technically simple to perform and is associated with satisfactory outcomes and low morbidity. mGMT should be considered an option for the treatment of RP in elderly patients. [ABSTRACT FROM AUTHOR]

Aim: Treatment of complex anal fistula (CAF) is challenging, often requiring multiple operations due to a high failure rate. The plethora of options attests to the lack of a panacea. Endorectal advancement flap (ERAF) carries the advantages of no sphincter division, no contour defect to the anal canal and no perineal wound. The failure rate of this procedure ranges between 15% and 60%. Although the procedure traditionally described a rhomboid (tongue‐shaped) flap, an elliptical (curvilinear) flap was introduced to try to improve the results. This study aimed to describe the elliptical‐shaped ERAF performed by the senior authors and others and compare failure rates between elliptical and rhomboid ERAFs for CAF. Method: A retrospective review of all patients who underwent ERAF for CAF between 2011 and 2017 was undertaken. Patients were divided into two groups based on the type of flap: rhomboid or elliptical. The main outcomes measures were postoperative persistent or recurrent fistula. Results: Seventy‐six ERAF procedures for CAF were identified in 71 patients; 39 had a classic rhomboid flap and 37 had an elliptical configuration with mean follow‐up of 13.8 and 13.9 months, respectively. The groups were similar for demographic parameters and preoperative fistula characteristics. The overall failure rate was 37%, with a success rate of 64% in the rhomboid and 62% in the elliptical group. Conclusion: The shape of the ERAF for treatment of CAF does not appear to influence failure rate. [ABSTRACT FROM AUTHOR]

Abstract: Aim: A longstanding disparity exists between the approaches to restorative surgery after colectomy for patients with ulcerative colitis (UC) in England and Sweden. This study aims to compare rates of colectomy and restorative surgery in comparable national cohorts. Method: The English Hospital Episode Statistics (HES) and Swedish National Patient Register (NPR) were interrogated between 2002 and April 2012. Patients with two diagnostic episodes for UC (age ≥ 15 years) were included. Patients were excluded if they had an episode of inflammatory bowel disease or colectomy before 2002. The cumulative incidences of colectomy and restorative surgery were calculated using the Kaplan–Meier method. Results: A total of 98 691 patients were included in the study, 76 129 in England and 22 562 in Sweden. The 5‐year cumulative incidence of all restorative surgery after colectomy in England was 33% vs 46% in Sweden (P‐value < 0.001). Of the patients undergoing restorative surgery, 92.3% of English patients had a pouch vs 38.8% in Sweden and 7.7% vs 59.1% respectively had an ileorectal anastomosis (IRA). The 5‐year cumulative incidence of colectomy in this study cohort was 13% in England and 6% in Sweden (P‐value < 0.001). Conclusion: Following colectomy for UC only one‐third of English patients and half of Swedish patients underwent restorative surgery. In England nearly all these patients underwent pouches, in Sweden a less significant majority underwent IRAs. It is surprising to demonstrate this discrepancy in a comparable cohort of patients from similar healthcare systems. The causes and consequences of this international variation in management are not fully understood and require further investigation. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Crohn's anal fistula should be managed by a multidisciplinary team. There is no clearly defined ‘patient pathway’ from presentation to treatment. The aim of this study was to describe the patient route from presentation with symptomatic Crohn's anal fistula to starting anti‐tumour necrosis factor (anti‐TNF) therapy. Method: Case note review was undertaken at three hospitals with established inflammatory bowel disease services. Patients with Crohn's anal fistula presenting between 2010 and 2015 were identified through clinical coding and local databases. Baseline demographics were captured. Patient records were interrogated to identify route of access, and clinical contacts during the patient pathway. Results: Seventy‐nine patients were included in the study, of whom 54 (68%) had an established diagnosis of Crohn's disease (CD). Median time from presentation to anti‐TNF therapy was 204 days (174 vs 365 days for existing and new diagnosis of CD, respectively; P = 0.019). The mean number of surgical outpatient attendances, operations and MRI scans per patient was 1.03, 1.71 and 1.03, respectively. Patients attended a mean of 1.49 medical clinics. Seton insertion was the most common procedure, accounting for 48.6% of all operations. Where care episodes (‘clinical events per 30 days’) were infrequent this correlated with prolongation of the pathway (r = −0.87; P < 0.01). Conclusion: This study highlights two key challenges in the treatment pathway: (i) delays in diagnosis of underlying CD in patients with anal fistula and (ii) the pathway to anti‐TNF therapy is long, suggesting issues with service design and delivery. These should be addressed to improve patient experience and outcome. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Increasing scrutiny on both individual and unit outcomes after surgical procedures is now expected. In the field of inflammatory bowel disease, this is particularly pertinent for outcomes after ileoanal pouch surgery. Method: The Surgical Workload and Outcomes Research Database (SWORD) relies on administrative data derived from Hospital Episode Statistics collected in England. The platform was interrogated for pouch procedures undertaken in England between April 2009 and December 2016 to assess national caseload and, between April 2012 and December 2016, to assess variation in caseload and outcomes after pouch surgery. Results: In England there is a suggestion that numbers of pouch procedures may be decreasing. Over 80% of Trusts offering pouch surgery do so at very low volume with less than five procedures per year. There is also a clear phenomenon of the occasional pouch surgeon with 126 surgeons undertaking just one pouch operation during the study period of almost 5 years. Laparoscopic practice varies but 60% of pouches overall were done via an open approach. Mean length of stay was 10.1 days and average 30‐day readmission rates were 27.4%. Outside London there appears to be an increasing trend for higher volume units to do more adult pouch procedures and lower volume units to do fewer. Conclusion: Low volume units and occasional pouch surgeons present a strong argument for centralization of pouch surgery. Data from England outside London suggest that this may already be happening. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis is an alternative to abdominoperineal excision of the rectum (APR) for low rectal cancer. Neorectal prolapse is an unusual complication following TATA. This study aimed to determine the incidence of neorectal prolapse after TATA for low rectal cancer. Method: This cohort study was conducted in a tertiary referral colorectal centre. From a prospectively maintained database including 1093 patients treated for rectal cancer between 1984 and 2016 we identified those who underwent sphincter‐preserving surgery. Data regarding the incidence, management and outcomes of neorectal prolapse were analysed. Results: A total of 409 patients were identified, of whom 185 underwent open surgery and 224 a minimally invasive surgical procedure (MIS). All received neoadjuvant chemoradiation. Neorectal prolapse occurred in 4.6% (n = 19) with an incidence of 2.2% in the open and 6.7% in the MIS group (P = 0.023), with no difference between MIS techniques. There was one recurrence of neorectal prolapse (5.9%). The incidence of neorectal prolapse was higher in women (9.5%) than men (2.5%) (P = 0.011). There were no differences in local recurrence rates between the neorectal prolapse group (5.3%) and our population without prolapse (3.4%) (P = 0.79). Conclusion: Neorectal prolapse is a rare occurrence following minimally invasive sphincter‐saving surgical procedures performed for rectal cancer. It appears to be more frequent in patients who undergo MIS procedures and in women. [ABSTRACT FROM AUTHOR]

Abstract: 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 10‐year single‐centre experience of recurrence after local excision for T1 rectal cancer. Method: Data were collected prospectively on all patients undergoing local excision by transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10‐year period were analysed. Results: In all, 192 patients underwent TEM for rectal cancer; 70 of these had T1 tumour in the TEM specimen and did not have preoperative radiotherapy. Four were managed with completion surgery following TEM and a further six had radiotherapy; 60 underwent surveillance alone. Local recurrence occurred in six patients; three underwent salvage surgery. Estimated local recurrence at 3 years was 7.2% for the surveillance alone group. Conclusions: Local recurrence rates were lower than previous studies. Better preoperative assessment, more effective local excision surgery and postoperative radiotherapy may be contributory factors to a better‐than‐predicted outcome. Local excision should be offered as part of standard of care for T1 rectal cancer in the presence of good preoperative selection and meticulous surveillance. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The long‐term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long‐term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome. Method: This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy‐four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included. Results: Seventy‐four patients [66 women; median age 61 (29–77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow‐up. Twenty‐three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10‐year follow‐up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro‐gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence. Conclusions: Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however. [ABSTRACT FROM AUTHOR]