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Background: A prognostic scoring model has been devised previously to predict survival following primary tumor resection in patients with metastatic colorectal cancer and unresectable metastases. This has yet to be validated., Objective: The main objectives of this study are to validate the proposed prognostic scoring model and create an interactive online calculator to estimate an individual's survival after primary tumor resection., Design: Clinical data and survival outcomes of patients were extracted from a prospectively maintained database. Patients were categorized into good, moderate, or poor survivor groups based on the previously proposed scoring algorithm. Discrimination was assessed and recalibration was performed, with the recalibrated model implemented as an interactive Web application to provide individualized survival probability., Settings: This study was conducted at a tertiary referral center., Patients: The study included 324 consecutive patients with metastatic colorectal carcinoma and unresectable metastases who underwent primary tumor resection between January 2008 and December 2013., Main Outcome Measures: The primary outcome measured was overall survival., Results: Three hundred twenty-four patients were included in the study. Median survival in the good, moderate, and poor prognostic groups was 56.8, 25.7, and 19.9 months (log rank test, p = 0.003). The κ statistic was 0.638 and RD was 0.101. Significant differences in survival were found between the moderate and good prognostic groups (HR, 2.79; 95% CI, 1.51-5.15; p = 0.001) and between poor and good prognostic groups (HR, 4.12; 95% CI, 1.98-8.55; p < 0.001). The model was implemented as an interactive online calculator to provide individualized survival estimation after primary tumor resection (http://bit.ly/Stage4PrognosticScore)., Limitations: Selection bias and single-center data preclude the generalizability of the proposed model. Information regarding the severity or likelihood of developing symptoms from the primary tumor were also not accounted for in the prognostic scoring model proposed., Conclusions: The prognostic scoring model provides good prognostic stratification of survival after primary tumor resection and may be a useful tool to predict survival after primary tumor resection. See Video Abstract at http://links.lww.com/DCR/A330.

Purpose: This study examined the mutational profile of the adenomatous polyposis coli gene in relation to the development of desmoid tumors in familial adenomatous polyposis patients from a predominantly Chinese population., Methods: This is a retrospective review of all patients with familial adenomatous polyposis coli from the Singapore Polyposis Registry. Identification of specific adenomatous polyposis coli gene mutation was performed and clinical course of associated desmoid disease obtained from case records and a computerized database., Results: Two hundred five patients from 75 families afflicted with familial adenomatous polyposis coli were reviewed, with gene mutations identified in 107 patients. Of these, 23 (11.2 percent) developed desmoids. The male-to-female ratio was 1:1.3 and the ethnic distribution was Chinese (n=17) and Malay (n=6). Of the 92 patients with mutations 5' to codon 1444, 11 patients (12 percent) developed desmoids compared with 6 of 15 (40 percent) patients with adenomatous polyposis coli gene mutations 3' to codon 1444 (P<0.01). The clinical course of desmoid tumors can be divided into stable (n=11), variable (n=3), progressive (n=6), and aggressive growth (n=3). Only 3 (13 percent) patients with aggressive tumor growth required chemotherapy. There was no correlation between the site of mutation and the clinical progression of the desmoids. Seventy-four percent of these desmoids (17/23) developed at a mean interval of 2.98 years after restorative proctocolectomy, while only 30 percent (7/23) were diagnosed preoperatively or discovered during the initial surgery. The most common complications related to the mesenteric desmoids were intestinal obstruction (21.7 percent), ureteric obstruction (17.4 percent), and encasement of superior mesenteric vessels (13 percent)., Conclusion: The clinical course of desmoids in an individual familial adenomatous polyposis patient remains unpredictable and no reliable genetic marker is available for prognostication in desmoid disease.

Background: This is a prospective, randomized, controlled trial comparing the outcome of intraoperative colonic irrigation with that of manual decompression for acutely obstructing colorectal cancers distal to the splenic flexure., Methods: All patients admitted to our department from June 1999 to August 2002 with obstructing left-sided colorectal cancers were recruited. Patients were randomized intraoperatively and were excluded if deemed unsuitable for segmental resection and primary anastomosis. Twenty-five patients were randomized to receive colonic irrigation and twenty-eight to receive manual decompression. Perioperative parameters and outcome including mortality and anastomotic leak were recorded., Results: Both groups of patients were comparable in terms of gender and age. The time taken for mobilization, decompression, and irrigation in the colonic irrigation group (median, 31 minutes) was significantly longer than that for the manual decompression group (median, 13 minutes) (P; = 0.0005). However, the total time of the operation was similar for both groups. Times for recovery of bowel function, of wound infection, and until discharge from the hospital were also similar. In the manual decompression group there were two cases of anastomotic leak (8 percent, 2/25) requiring reoperation but none (0/24) in the colonic irrigation group. However, this difference was not statistically significant., Conclusion: Manual decompression of proximal colon without irrigation is as safe as colonic irrigation in one-stage surgical management of obstructing left-sided colorectal cancer.

Introduction: A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis from an anastomotic dehiscence after a coloanal or low colorectal anastomosis. Such a stoma is usually closed after 6 to 12 weeks when the intestinal edema is reduced and the peristomal adhesions are less dense. This period is three to four times longer than necessary for assurance of anastomotic healing, which is usually achieved by the second week after surgery. With the use of a bioresorbable membrane to minimize the formation of peristomal adhesions, earlier closure is hypothetically possible at three weeks., Methods: Patients undergoing creation of a defunctioning ileostomy were randomized in Phase I either to have an adhesion barrier membrane wrapped around the limbs of the ileostomy, with closure at three weeks, or to the control group, with no barrier membrane and closure after more than six weeks. In the subsequent Phase II, the efficacy of the barrier membrane was compared in a similar manner with a control group at ileostomy reversal after three weeks. Peristomal adhesions at the time of stomal mobilization were scored in a blinded manner., Results: In Phase I, no statistically significant differences were noted in the mean adhesion scores between the two groups (7.42 vs. 7.28). However, in Phase II, when peristomal adhesions at closure were compared at three weeks for both groups, with and without adhesion barrier placement, there was a significant reduction in the overall mean adhesion scores (5.81 vs. 7.82, respectively). The number of patients with dense adhesions was also reduced in the adhesion barrier group. There was no significant difference in the time taken and the difficulty encountered during ileostomy closure in the two groups. A tendency to easier closure, as evidenced by a lower incidence of perioperative complications, was noted in the adhesion barrier group., Conclusion: An adhesion barrier membrane placed around the limbs of a defunctioning loop ileostomy reduces peristomal adhesion and facilitates early closure at three weeks with minimal complications.

Purpose: The aim of this study was to compare the bowel function of sigmoid vs. descending colonic J-pouches after ultralow anterior resection for rectal cancer., Methods: A prospective, randomized trial was conducted from March 1998 to September 1999. Ninety-two consecutive patients undergoing ultralow anterior resection for cancers arising from 3 to 10 cm from the anal verge were recruited. Forty-eight patients were males; the mean ages (standard error of the mean) for patients with sigmoid and descending colon pouches, respectively, were 65.2 (3.1) years and 62.3 (3.1) years. A total of 46 patients were randomly assigned to each group. Two patients from each group were excluded; abdominoperineal resection was performed for two patients in the sigmoid pouch group and one patient in the descending pouch group. One patient in the descending pouch group had a transanal resection of a benign polyp. Dukes staging and use of postoperative chemoradiotherapy were statistically similar in both groups. All patients underwent a standardized ultralow anterior resection. A defunctioning loop ileostomy was used routinely. Anorectal physiology and bowel function questionnaires were performed at six weeks after ileostomy closure and again at 6 and 12 months after surgery., Results: Median follow-up was 12 (range, 7 to 25) and 12 (range, 6 to 25) months, respectively, for sigmoid and descending pouch groups. Median tumor and anastomotic heights, time to ileostomy closure, operative time, and postoperative stay were statistically similar in both groups. There were no significant differences in stool frequency, incontinence, urgency, use of pads and antidiarrheals, sensation of incomplete evacuation, and anorectal physiology results between groups (P > 0.05)., Conclusion: Pouches made from sigmoid or descending colon give similar bowel function after ultralow anterior resection for rectal cancers.

Introduction: A rat model of long-term colonic intubation has been developed to facilitate the in vivo study of colonic biology. This study aims to characterize this model., Methods: The effects of intubation and sham surgery on animal behavior and weight gain were measured and compared with unoperated controls. The reproducibility of the model was assessed by comparing complication and failure rates for three operators. The distribution and excretion of infused materials were studied using radiology and gas chromatography of feces, respectively. The effects of the colonic tube and infusions on the mucosa were assessed histologically., Results: There was about 10 percent weight loss postoperatively, more marked in those rats undergoing more extensive surgery. Subsequent weight gain was similar in all groups, and no behavioral effects of surgery were noted. There were no differences in histologic appearances or proliferative indices among the groups. All three operators had similar complication and tube dislodgement rates. Radiologic examination showed even distribution of infusate regardless of fecal consistency. Infusion through the two tubes allowed the cecum and the distal bowel to be targeted differentially. The infusions did not alter the consistency of the fecal pellets or induce defecation. Gas chromatography at various time points after butyrate infusion showed a small, but statistically insignificant, rise in fecal excretion, representing less than 10 percent of the infused butyrate., Conclusions: A highly reproducible in vivo rat model, with an experimental life span of five to six weeks, has been achieved. Biological agents can be accurately delivered via the colonic tubes and are retained in the colonic segment of interest. This intubation model should provide a valuable tool in the future for in vivo studies of colonic biology.

Purpose: Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique., Methods: A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs., Results: Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005)., Conclusions: Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Purpose: An erect chest radiograph for subdiaphragmatic free gas can be a useful adjunct in detecting a defect in gastrointestinal continuity. The usefulness of this test after laparotomy has not been defined, because the period of persistence of free gas is unknown. We set out to determine the length of time for natural absorption of postlaparotomy pneumoperitoneum in a prospective cohort study., Method: Plain erect chest radiographs were performed on the second and fourth postoperative day and daily thereafter until the disappearance of subdiaphragmatic free gas after laparotomy., Results: Seventy-five consecutive patients were studied after informed consent. The mean age was 62.1 (standard error of the mean, 1.7) years. On the fifth postoperative day, sixth postoperative day, and seventh postoperative day, 71.6, 80, and 89 percent of patients, respectively, had no visible subdiaphragmatic gas. Five patients had gas persisting beyond the tenth postoperative day. Two of these patients did not have an anastomosis. The use of drainage tubes did not affect significantly the mean time to disappearance of subdiaphragmatic free gas (4.5 vs. 4.9 days; P = 0.45: t-test). The duration of surgery, body mass index, and time to resume bowel function had no significant effect on gas disappearance. Two patients had a clinical leak on the fifth postoperative day. This was manifested as an increase in the collection of subdiaphragmatic gas during the course of a day., Conclusion: By the sixth postoperative day 80 percent of patients had no subdiaphragmatic free gas on an erect chest radiograph regardless of the presence of a drainage tube. The erect chest radiograph may therefore be a simple and readily available adjunct in the evaluation of postoperative abdominal pain, especially after the sixth postoperative day when a similar prior examination is done routinely on the fourth postoperative day for comparison.

Purpose: Injury sustained from the transanally introduced stapling technique was assessed by comparison with biofragmentable anastomotic ring anastomosis, which excluded anal manipulation., Methods: A randomized, controlled trial was conducted on consecutive patients undergoing sigmoid colectomy (where pelvic nerve injury was avoided). A bowel function questionnaire was administered six months after surgery. Anorectal manometry and endoanal ultrasonography were performed preoperatively and at six months postoperatively. The observers were blinded to the randomization., Results: There were 18 patients in the transanally introduced stapling technique group and 17 patients in the biofragmentable anastomotic ring group, with no differences in age, gender, Dukes staging, and follow-up. Three of the transanally introduced stapling technique patients had occasional liquid soiling, which was absent in biofragmentable anastomotic ring patients. Mean change in resting anal pressures was also significantly impaired when compared with patients with biofragmentable anastomotic ring (P = 0.007). Endosonographic internal sphincter fragmentation was found in five transanally introduced stapling technique patients but none after biofragmentable anastomotic ring anastomosis (P = 0.046). Internal sphincter fragmentation was associated with the impaired resting pressures (P = 0.007). External sphincter deficiencies were found after transanally introduced stapling technique in two patients (biofragmentable anastomotic ring = 0), and these were associated with the soiling (P = 0.005)., Conclusions: The transanally introduced stapling technique may result in anal sphincter defects and impaired anal pressures when assessed at six months of follow-up.

Purpose: Rectocele is often associated with anorectal symptoms. Various surgical techniques have been described to repair the rectocele. The surgical results are variable. This study evaluated the results of transanal repair of rectocele, with particular emphasis on the impact of concomitant anismus on postoperative functional outcome., Methods: Fifty-nine consecutive females who underwent transanal repair of rectocele for obstructed defecation were prospectively reviewed. All 59 patients were parous with a median parity of 2 (range, 1-6) and a median age of 58 (range, 46-68) years. The median length of follow-up was 19 (range, 6-40) months. Anismus was detected by anorectal physiology and defecography. The functional outcome was assessed by a standard questionnaire, physical examination, anorectal manometry, neurophysiology, and defecography. The quality-of-life index was obtained using a visual analog scale (from 1-10, with 10 being the best)., Results: The functional outcome of transanal repair of rectocele was superior in patients without anismus. Forty (93 percent) of the 43 patients without anismus showed improved evacuation after repair compared with 6 (38 percent) of the 16 patients with anismus (P<0.05). The quality-of-life index improved (9 vs. 4) if anismus was not present (P<0.05). There were minimal complications. Hemorrhage requiring blood transfusion (2 units) occurred in one patient and urinary retention in another., Conclusion: Transanal repair of rectocele is safe and, in the absence of anismus, effectively corrects obstructed defecation.

Purpose: A free-living animal model with ready and repetitive access to selected regions of the large bowel and with minimally altered bowel anatomy and physiology would facilitate the in vivo study of luminal factors on the colonic mucosa in a steady-state environment. This study describes a novel model of large-bowel intubation in the rat., Method: Four Sprague-Dawley rats (240-260 g) had laparotomy and intubation of the distal colon and the cecum via a cecotomy with the use of two small tubes with restraints and transmural anchors. The tubes were tunneled and anchored to the back for infusion of fluid directly into the colon. Tube positions were studied when the animals were killed. Animals were fed on either a 10 percent fiber diet or a fiber-free diet. Stathmokinetic assessment of the distal colon was performed after one week of infusion with phosphate-buffered saline and sodium n-butyrate., Results: The technique produced an easy access without affecting the weight gain of the animals after recovery. Tube positions were accurate after three weeks at the time the animals were killed. Infusions of phosphate-buffered saline and n-butyrate were well tolerated. n-Butyrate infusions twice daily for a week reversed the atrophy in the colonic mucosa induced by dietary fiber deprivation., Conclusion: An in vivo large-bowel intubation model permitting selective delivery of luminal factors provides an effective option for the study of colonic mucosal biology.

Purpose: Incision and drainage (I & D) with concurrent or delayed fistulotomy is the usual treatment for abscess-fistula with a demonstrated internal opening. We compared incision and drainage alone vs. with concurrent fistulotomy for perianal abscesses with a demonstrated internal opening., Methods: Consecutive patients with acute perianal abscesses and a demonstrated internal opening were prospectively randomized into either the I & D group or drainage with concurrent fistulotomy group. They were followed up at one month, three months, and one year., Results: The I & D group had 21 patients, and the fistulotomy group had 24 patients. Thirteen patients had low intersphincteric abscess-fistula, and seven had low transsphincteric fistulas in the I & D group. The fistulotomy group had 9 intersphincteric abscess-fistula compared with 14 low transsphincteric ones. Median duration of surgery, hospital stay, and continence at final follow-up were the same in the two groups. Three had recurrent abscess-fistula in the I & D group compared with none in the fistulotomy group (P = 0.09)., Conclusion: I & D alone for acute anal abscess-fistula with demonstrated internal opening showed a tendency to recurrence that did not reach a statistically significant difference compared with concurrent fistulotomy. I & D, therefore, puts only a few patients at risk for recurrence.