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Aim: The results including function and quality of life (QOL) of restorative proctocolectomy (RPC) performed in children and adolescents with ulcerative colitis (UC), familial adenomatous polyposis (FAP) and idiopathic megarectum were determined., Method: Twenty-one patients of a median age of 15 (10-17) years underwent RPC between 1995 and 2006. The indication, use of covering ileostomy, morbidity and mortality were recorded. A structured questionnaire was completed by telephone interview to assess long-term function. The Cleveland Clinic Scoring (CCS) System was used for the assessment of faecal incontinence and the modified McMaster proforma for QoL., Results: There was no mortality. At a median follow-up of 65.5 (26-168) months, all patients had an intact pouch. One had a long-standing ileostomy. Median daytime and nocturnal stool frequencies were 4 (2-16) and 0 (0-3). The mean CCS was 1.47, with only one patient scoring more than 10. Eighteen of 20 patients were satisfied with the result; two patients had a worse QoL (McMaster score >8). One patient had a permanent stoma following pouch sepsis and one had symptoms of pouchitis., Conclusion: RPC can be performed in children and adolescents with good functional outcome and acceptable QoL., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Objective: Local recurrence of rectal cancer is a major cause of morbidity and mortality following curative resection. The published rates vary after abdomino-perineal resection (APR) from 5% to 47%. The aim of this study was to evaluate local recurrence following curative APR for low rectal cancer in our unit., Method: The medical notes of patients treated between 1st January 1996 and 31st December 2000 were retrieved. Local recurrence was defined as the presence of tumour within the pelvis confirmed by clinical findings, pathological specimen or radiological reports. A curative resection was defined as excision of tumour in the absence of macroscopic metastatic disease and whose resection margins were greater than 1 mm circumferentially and 10 mm distally. Outcomes and survival were compared using Fisher's exact test and Kaplan-Meier method., Results: Two hundred consecutive cases with a diagnosis of rectal cancer were identified of which 139 underwent a curative resection (69.5%). Of these 40 patients (28%) underwent APR with curative intent. Two patients (5%) developed local recurrence at 18 and 24 months respectively. The overall local recurrence rate for all curative rectal cancer surgery, in the same period was 2.6%. Eleven patients have died in the follow-up period of which nine were cancer-related deaths., Conclusion: The local recurrence rates achieved with APR were not significantly different from those achieved with restorative operations. Tumours at the ano-rectal junction should not be dissected off the pelvic floor, but radically excised en bloc with the surrounding levator ani, as a cylinder, as originally described by Miles.

Introduction: Obstructed defaecation is a complex disorder that poses serious management challenges. The purpose of this study is to review the functional results of surgery in women undergoing rectocele repair for obstructed defaecation, and in a targeted subgroup in which the rectocele was the only identifiable cause of their symptoms., Methods: All case notes were reviewed. Demographic details, preoperative symptoms, details of previous pelvic surgery, radiological and anorectal physiology results, operative procedure, post operative symptoms, length of follow-up and details of further pelvic reconstructive surgery were recorded. To enter the targeted group, patients (i) had not undergone previous pelvic surgery, (ii) had presented with obstructive defaecation, (iii) had a proctogram that demonstrated a rectocele with no or partial intrarectal intussusception and (iv) had no other functional abnormality in colonic transit studies, endoanal ultrasound or anorectal physiology., Results: Eighty-two case notes were reviewed. All experienced obstructed defaecation. Forty-two women underwent a per-anal plication of the rectocele, 33 had a transperineal plication and levatorplasty and seven a mesh repair. A total of 63 (77%) women were pleased with the result, though symptoms later returned in 17 (27%) of them. 26 (31%) had further surgery in an attempt to improve their defaecatory difficulties. Sixteen women were eligible for the targeted group. All had a good early result though symptoms returned in three women. Two (12%) had further surgery., Conclusion: Careful preoperative patient selection is vital to improve outcomes. Preoperative counselling of all patients undergoing rectocele repair is of extreme importance, in particular explaining the evolving nature of pelvic floor dysfunction and the possible need for further reconstructive surgery.

Objective: Hypothermia may occur during general anaesthesia and is associated with postoperative coagulopathy, ischaemic cardiac events, wound infections and increased metabolic expenditure due to shivering. The purpose of the present pilot study was to determine whether the administration of certain amino acids (Vamin 18) during general anaesthesia could prevent postoperative hypothermia., Patients and Methods: Two groups of patients were studied. The study group comprised 10 patients who underwent complex major colorectal operations. In this group an infusion of 500 mls of Vamin 18 (Fresenius Kabi Ltd) was commenced immediately after induction of anaesthesia but prior to the skin incision. In a control group (n=10) who underwent similar surgical procedures Vamin 18 was not administered. In both groups core body temperature, using an oesophageal probe was recorded during the procedure and recovery period. Ambient theatre and recovery room temperature and other body warming techniques were standardized for all patients. Statistical analysis was performed using t-test for comparison of linear temperature changes at different times during the procedure for both groups of patients., Results: The body temperature was statistically significantly reduced in both groups at skin incision when compared with temperature prior to induction of anaesthesia. (, Study Group: mean 0.74 degrees C, SD=0.38, P =<0.001;, Control Group: mean 0.54 degrees C, SD=0.43, P=0.003]. The increase in body temperature between the time of skin incision and recovery period was statistically significant (P=0.012) in the study group but not so in the control group (P=0.730)., Conclusion: The results of the present pilot study demonstrate that complex colorectal operations are associated with a decrease in body temperature which is most marked immediately after the induction of anaesthesia. The perioperative administration of Vamin 18 appears to increase the rate of recovery of body temperature. The impact of this thermogenic effect on perioperative morbidity and mortality should be studied in a prospective randomised clinical trial.

Objective: The treatment of chronic fissure may be medical or surgical. Indications for assessment, which is the better treatment and under what circumstances, are vital for the appropriate management. The aim of the study was to assess the management of this condition by an expert group of surgeons., Methods: Consultant members of the Association of Coloproctology of Great Britain and Ireland (n=452) were approached and requested to answer a preset multiple-choice questionnaire. The questionnaire was designed to assess their management strategy and their approach to investigation and treatment under different clinical situations., Results: The overall response was 78% (n = 356). Medical treatment was the first line treatment in 95% of the responders. Lateral anal sphincterotomy without pre-operative endoanal ultrasound and/or anorectal physiology was performed by 57%. Anal dilatation was performed selectively by 36% but only 35% of these would perform a pre-operative endoanal ultrasound or anorectal physiology., Conclusion: In the selected group of clinicians lateral anal sphincterotomy remains the procedure of choice in both sexes. Pre-operative assessment using endoanal ultrasound and anorectal physiology is used selectively especially in postpartum women. Anal dilatation remains a subjective procedure and though used selectively, is performed without pre-operative endoanal ultrasound and/or anorectal physiology in majority of cases.

Introduction: There have been many surgical techniques described for the treatment of pilonidal sinuses. Recurrent disease causes significant morbidity particularly with time from work., Aim: To assess the rhomboid flap's role in promoting one-stage primary healing in pilonidal disease and to evaluate the morbidity and recurrence., Methods: Fifty-three patients were prospectively recruited of which 27 had previous multiple abscess formation requiring surgical drainage from their pilonidal disease, although none had acute disease at the time of surgery. By using the transposition flap, we were able to obliterate the natal cleft and therefore the rolling action of the buttocks between the cleft in these patients and thereby remove one of the factors involved in pilonidal disease. Hospital stay, healing time, wound infection, wound breakdown and recurrence were noted., Results: There were 47 males and 6 females with a median age of 28 years (range 16-64 years). Median follow-up was 24 months (range 3-36 months). Post-operative morbidity involved superficial wound infection in 7 (13%) which settled with out-patient dressings. There were four recurrences (7%), two occurred between the flap and the anal canal, and the other two in the flap margin needing intervention. All the patients healed their wounds and the median healing time was 14 days., Conclusion: As this condition affects a predominantly young population causing significant time off from work, we feel that the Rhomboid Flap is useful for difficult cases in that it allows early return to full activity and does not necessitate prolonged postoperative care.

Aim: To prospectively audit stomas and to determine the nature and rate of complications and their relationship with various risk factors and their management., Materials and Methods: The study was performed prospectively on 97 consecutive patients who had stomas formed between January 2000 to August 2000. Patients were followed up for one year. Risk factors including age, body mass index (BMI), preoperative siting, contour of the abdominal wall, smoking, grade of operating surgeon, emergency or elective procedure, diabetes, type of stoma and suture material used were noted. The type of surgery, and indications for surgery were also recorded. The complications were documented by two qualified stoma nurses and a photographic record taken. Statistical analysis comprising both univariate and multivariate methods, was performed by SPSS 10., Results: The mean age was 65 years (standard deviation 16.01, range 16-99) and mean body mass index was 24.5 (standard deviation 4.66, range 15-37). Forty-nine of 97 (50.5%) stomas developed one or more complications. Twenty-three patients experienced retraction, 18 had stomas sited in a skin crease, 16 had early and 12 had late skin excoriation, 12 had detachments and a further 12 had parastomal hernia. Eleven further stoma complications were noted including prolapse, necrosis, ischaemia and sloughing. None of the risk factors achieved statistical significance when analysed against the overall complication rate. However, when the risk factors were analysed against individual complications using univariate logistic regression, a high body mass index was associated with more retractions (P = 0.003), early skin excoriation (P = 0.036) and poor siting (stoma in crease) occurred more commonly in emergencies (P = 0.022). Diabetes was associated with late skin excoriation (P = 0.02). Multivariate logistic regressions confirmed an independent association of body mass index, diabetes and emergency surgery with complications. Forty-five of 49 patients who had complications needed some conservative management such as a convexity appliance. Four patients needed refashioning., Conclusion: Body mass index, diabetes and emergency surgery were the significant risk factors identified in our study. Overall complications compare favourably with other series. We found that preoperative siting by stoma nurses and the grade of operating surgeon did not affect the outcome.