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Aim: Assessment of the chest in colorectal cancer (CRC) staging is variable. The aim of this review was to look at different chest staging strategies and determine which has the greatest efficacy., Method: A review of studies assessing chest staging modalities for patients with CRC was performed. Modalities included chest X-ray (CXR), CT and positron emission tomography (PET)., Results: The majority of data consisted of case series. Two studies identified a low pick-up rate for CXR as a staging tool. Five studies showed increased detection rates of pulmonary metastases for chest CT vs CXR and abdominal CT. The clinical benefit of the increased detection rates was not clear. The incidence of indeterminate lung lesions (ILL) on staging chest CT varied from 4 to 42%. The majority (≥ 70%) of ILLs did not have any clinical significance. On CT scans, the incidence of pulmonary metastases in patients with rectal cancer ranged from 10 to 18% and in patients with colon cancer the incidence of pulmonary metastases ranged from 5-6%. The incidence of synchronous liver and pulmonary metastases compared with the overall incidence of pulmonary metastases ranged from 45 to 70%. There was no evidence reporting the superiority of PET/CT vs CT for the detection of pulmonary metastases or characterization of ILL., Conclusion: Studies show that chest CT scanning increases the detection rates for ILL and pulmonary metastases. The clinical benefit of the increased detection rates is not clear. There is a paucity of data assessing the optimal chest staging strategy for patients presenting with CRC., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Aim: End-stage renal failure (ESRF) and renal transplant recipients are thought to be associated with an increased risk of colorectal complications., Method: A review of the literature was performed to assess the prevalence and outcome in both benign and malignant colorectal disease., Results: No prospective randomized studies assessing colorectal complications in ESRF or renal transplant were identified. Case series and case reports have described the incidence and management of benign colorectal complications. Complications included diverticulitis,infective colitis, colonic bleeding and colonic perforation. There was insufficient evidence to associated iverticular disease with adult polycystic kidney disease.Three population-based studies have shown up to a twofold increased incidence of colonic cancer but not rectal cancer for renal transplant recipients. Bowel cancer screening (as per the general population) by faecal occult blood testing appears justified for renal transplant patients; however, evidence suggests that consideration of starting screening at a younger age may be worthwhile because of an increased risk of developing colonic cancer.Two population-based studies have shown a threefold and 10-fold increased incidence of anal cancer for renal transplant recipients. A single case–control study demonstrated significant increased prevalence of anal human papilloma virus (HPV) and intraepithelial neoplasia (AIN)in patients with established renal transplants., Conclusions: Despite the lack of high-level evidence,ESRF and renal transplantation were associated with colorectal complications that could result in major morbidity and mortality. Bowel cancer screening in this patient group appears justified. The effectiveness of screening for HPV, AIN and anal cancer in renal transplant recipients remains unclear.

Objective: An improved understanding of the pathophysiology of haemorrhoids has resulted in the introduction of new surgical techniques including stapled haemorrhoidopexy (SH). This randomized controlled trial compared the long-term effectiveness of SH with rubber band ligation (RBL) in the treatment of grade II circumferential symptomatic haemorrhoids., Method: A consecutive cohort of patients was randomly allocated to either SH or RBL. Data on haemorrhoidal symptoms, Cleveland continence scores, sphincter assessment, SF-36, EQ-5D, HAD score and prior treatment history were assessed at enrollment and reassessed by long-term postal questionnaire. The details were analysed using spss 12.0 from Microsoft Access., Results: Sixty patients were allocated by computer block randomization. Both groups were balanced for age, sex and symptoms. Recurrence favoured SH [3 vs 11; OR 0.18, 95% CI (0.03 to 0.86), P = 0.028] at 1 year and, at a mean of 40.67 (31-47) months [4 vs 12; OR 0.23, 95% CI (0.05, 0.95); P = 0.039]. SH patients experienced prolonged pain [Median (IQR) = 7 (5,7) vs 3 (1,7), P = 0.008] and took a longer time to return to work [6 (3,7) vs 3 (1,6) days, P = 0.018]. This was no significant difference in quality of life., Conclusion: Stapled haemorrhoidopexy achieved better disease control at 1 year without any major complication. This was sustained in the long-term. Further studies with greater patient numbers are needed to confirm this study.

Objectives: Haemorrhoidal disease is a common condition causing considerable distress to individuals and significant cost to healthcare services. This paper explored the cost-effectiveness of stapled haemorrhoidopexy (SH) compared with the non-surgical intervention, rubber band ligation (RBL), for grade II symptomatic circumferential haemorrhoids., Method: An economic evaluation alongside a randomized controlled trial conducted between October 2002 and February 2005. Adults were recruited and randomized to either SH or RBL. The same surgeon performed all procedures and investigators were blinded until analyses were completed. Primary outcomes measured at 52 weeks were cumulative costs to the NHS, clinical diagnosis of recurrence and quality adjusted life years (QALYs)., Results: Sixty symptomatic men and women with confirmed clinical diagnosis of grade II symptomatic haemorrhoids were randomized. Loss to follow-up was up to 10% at 52 weeks. The mean cost for SH was greater than RBL (mean difference: 1483 pounds, 95% CI: 1339-1676); disease recurrence was lower (OR = 0.18, 95% CI: 0.03-0.86); and there was no evidence of a statistically significant difference in QALYs (-0.014, 95% CI: -0.076 to 0.051). SH was associated with a modest incremental cost per recurrence avoided at 12 months follow-up (4945 pounds). Based on current data, it was considered highly unlikely to be cost-effective in terms of incremental cost per QALY., Conclusions: There is insufficient evidence about the cost-effectiveness of SH for grade II haemorrhoids to recommend its routine use in place of RBL. Further information is needed from larger trials with a longer-term follow-up to inform subsequent economic evaluation.

Background: Sacrococcygeal pilonidal is a common disease in active young adults. Many surgical methods have been proposed, although no clear consensus as to the optimal treatment has been reported. This review looks at the different surgical techniques available and examines the reported results of primary healing, recurrent disease and complications (including delayed healing)., Method: A literature search using the Medline database was performed to locate English language articles on surgery for pilonidal disease. Further articles were obtained from the references cited in the literature initially reviewed., Results: Management should be tailored according to the individual and whether the disease is acute or chronic. Treatment should take into consideration hospital stay and return to work. Simple excision, curettage, partial lateral wall excision, or marsupialisation, are simple techniques with good results. They can be used for the initial surgery but their use is not recommended for recurrent disease. The modified rhomboid flap for recurrent disease has consistently shown positive results in terms of complication rates and recurrence., Conclusion: We would recommend tailored treatment with simple excision for initial presentation and the modified rhomboid flap for recurrent disease.

Objective: The aim of this review was to determine the effects of epidural analgesia as it relates to outcome after colorectal surgery., Method: We searched and reviewed studies that included colorectal surgery and epidural method of analgesia listed on the Pubmed, Medline, Embase and the Cochrane library database., Results: The majority of data demonstrate a superior effect of epidural analgesia on pain control after colorectal surgery. Well designed randomized controlled trials (RCT's) have also shown that epidural analgesia reduces the duration of ileus after colorectal surgery. Limited data suggest the additional benefit may be minimal after laparoscopic surgery or when epidural analgesia is used as part of a multimodal regime. Data does not convincingly show either a clear harmful or beneficial effect of epidural analgesia on rates of anastomotic leakage. Epidural analgesia may have beneficial effects on postoperative lung function, however due to low numbers, the effects on cardiovascular and thromboembolic complications are indeterminate. Length of hospital stay has not been shown to be shortened by sole use of an epidural and, although epidural analgesia may be apparently more costly, alternatives may incur higher indirect costs and decreased patient satisfaction., Conclusion: Randomized controlled trials have shown a benefit for epidurals on postoperative pain relief, and ileus, and possibly respiratory complications. There is no proven benefit with regard to length of stay. There are a number of unresolved issues which further focussed RCT's may help clarify such as effects of epidural on complication rates after colorectal surgery.

The use of the antegrade continence enema (ACE) is becoming more widespread. Preliminary studies have been promising, but the procedure is not universally successful. A colonoscopic insertion of a caecostomy button is a relatively minor procedure. This allows the ACE to be used for a trial period to assess whether a permanent procedure would be beneficial. If successful, enemas can be continued by the caecostomy, or a formal ACE can be performed. We report a series of five patients who underwent staged endoscopic insertion of a MIC-KEY caecostomy button, and we discuss the technical aspects of the procedure.

Removal of locally advanced right-sided colonic carcinoma involving the duodenum can be challenging. There are few data on the optimal surgical approach. Adjacent organ involvement is associated with a poor prognosis and may be classified as inoperable with patients having palliative bypass procedures rather than primary resection. Survival is however improved after en bloc resection of adjoining viscera compared with intestinal bypass. We present a variety of surgical options depending on the extent of local invasion and the debility of the patient.

Introduction: Stapled haemorrhoidopexy is increasingly used for the surgical management of prolapsing haemorrhoids. Accurate placement of the staple line is essential to avoid involvement of the internal anal sphincter (IAS) and the pain sensitive squamous epithelium. The aim of this study was to correlate histology with symptomatic outcome after stapled haemorrhoidopexy., Patients and Methods: A single pathologist reviewed one hundred and six consecutive rectal mucosal specimens. Each specimen was assessed for the presence of columnar, transitional and squamous epithelium as well as involvement of smooth and skeletal muscle. In November 2003 all patients were sent a previously validated postal questionnaire about haemorrhoidal symptoms and a Cleveland Clinic continence scale. Symptomatic outcome was compared between patients who did or did not have squamous epithelium involvement in their pathology specimens and were analysed by Mann-Whitney U-test., Results: One hundred and six stapled haemorrhoidopexies were performed between June 2001 and September 2003. Eighty-four patients (79%) returned the questionnaire; 19 patients had squamous epithelium present in the pathology specimens. There was no significant difference between symptom or Cleveland Clinic scores in patients with or without squamous epithelium in their pathology specimens. Some specimens (n = 6) were found to have smooth muscle underlying squamous epithelium; this was interpreted as the presence of internal anal sphincter (IAS) within the specimen. There was no significant difference in Cleveland Clinic scores between this group and those without IAS involvement., Conclusion: This study has not demonstrated a long-term difference in symptomatic outcome or continence in patients who have squamous epithelium present in their stapled haemorrhoidopexy specimens.

Background: Colonic stents are increasingly used to palliate or alleviate large bowel obstruction in patients with colon cancer and other obstructing lesions in whom a definitive surgical procedure is inappropriate. We report on the outcomes of a large group of patients who underwent deployment of a colon stent in a single institution by a single operator., Patients and Methods: This was a retrospective observational cohort study of all patients undergoing colonic stenting between September 1995 and May 2002. Data collected included nature of pathology, type of stent used, procedure morbidity, patient survival and details of any definitive procedures performed after stenting., Results: One hundred and seven patients were evaluated (58 male) with a median age of 75 years (range 36-99 years). A total of 112 stents were successfully deployed (46 as an emergency). Twelve patients had double stents inserted coaxially and overlapping. In 7 patients the stent could not be safely deployed. Eighty-seven patients had colorectal cancer, 13 patients had an extra-luminal malignancy, 5 had diverticular strictures and in 2 patients the pathology was unknown. At last review (May 2002) 18 patients were alive, 82 patients had died and 7 patients had been lost to follow-up. Of those patients who died, the median survival after stenting alone was 6 weeks (range 4 days-36 weeks). Ten patients underwent subsequent definitive surgery. Stent complications included, 2 colonic perforations, 3 stent occlusions and 4 stent migrations., Conclusion: Colonic stenting can be used effectively, with acceptable morbidity, to manage patients presenting with large bowel obstruction. In a smaller number of patients colon stents may safely temporize symptoms while definitive surgery is planned.

Background: Colonic pouch formation with pouch-anal anastomosis is now regarded as the procedure of choice for restoration of intestinal continuity following anterior resection for low rectal cancers. The aim of this study was to review the necessity for routine colonic pouchography prior to closure of a diverting loop stoma., Methods: This was a prospective study of 52 consecutive patients who underwent colonic pouch formation between 1 June 1999 and 31 May 2002, four of whom have subsequently died. Each pouch was assessed clinically and radiologically prior to stoma closure., Results: There were no clinical anastomotic leaks. Forty-six of 48 surviving patients have had a colonic pouchogram and in no case was either a pouch or pouch-anal anastomotic defect identified. To date 40 patients have undergone stoma closure without an anastomosis-related complication., Conclusion: Following successful colonic pouch formation, routine study of the pouch by contrast radiology does not add to clinical assessment. As a consequence radiological imaging is unnecessary and can be omitted.