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PROCARE, a Belgian multidisciplinary project on rectal cancer, started in 2006 with participation on a voluntary basis. Completeness and bias of registration in PROCARE were assessed.Data from 6353 patients with rectal cancer were extracted from the population based Belgian Cancer Registry for the period 2006-2008. Registration bias was studied by comparing patient, tumour and treatment characteristics of cases registered and non-registered in PROCARE. Relative survival (RS) of patient subgroups was analysed.PROCARE included 37% of all Belgian rectal cancer patients. Registration was highly variable between participating centres which recorded on average 56% of their patients. Significant differences in patient, tumour and treatment related characteristics were observed between registered and non-registered patients. The 5-year RS was 77% (95% confidence interval (CI): 74-80%) for registered patients and 56% (95% CI: 53-59%) for non-registered patients. After adjustment for patient, tumour characteristics and volume of centre, the relative excess risk of dying (RER) between registered and non-registered patients was 2.15 (95% CI: 1.85-2.50, p0.001). The 5-year RS of patients treated in centres that never participated in the project was 59% (95% CI: 55-63%) and, after adjustment, the RER was 1.16 (95% CI: 1.00-1.35, p0.050) compared to patients of the participating centres.Registration of PROCARE patient data was incomplete, biased and variable between centres. Participation on a voluntary basis should be avoided for further projects. Quality assurance on a centre level requires compulsory and complete registration with a minimal but relevant data set for all patients treated in all centres.

Background Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited. Methods Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data. Results A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II–III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population. Conclusion Some volume effects were observed, but their effect size was limited.

Fast-track programs (ERAS) have been shown to improve postoperative recovery in colorectal surgery, combining newer anesthetic and minimally invasive surgery with evidence-based adjustments to facilitate revalidation. This prospective study evaluated the outcome of an ERAS protocol implementation in a university colorectal unit.Between 2009 and 2010, 94 patients (49 males and 45 females) underwent an elective colorectal resection and were included in this protocol. All data were prospectively gathered in an electronic database. A cohort comparison was performed with 120 patients operated on in 2008 before ERAS implementation.The median age was 58 years [range: 29-76 years] and the median ASA score was 2. All colorectal procedures (85 sigmoid resections, 7 right hemicolectomies and 2 low anterior resections) were performed laparoscopically, with a conversion rate of 9,5%. Complications were noted in 14 patients (14,9%); two patients (2,1%) required a laparoscopic drainage of an infected hematoma during initial hospital stay. A significant (p0,001) reduced median postoperative hospital stay of 4 days [range : 2-11 days] in the ERAS group, compared with 6 days [range : 3-37] in the non fast-track group was noted. Early readmission occurred in five patients (5,3%) because of anastomotic leakage (n = 2), ileus (n = 2) and a wound infection (n = 1).These results of length of stay, morbidity and readmission-rates have important implications for the organization of health care, waiting lists and costs. Therefore the ERAS principles should be more wide-spread implemented.

Rigid proctosigmoidoscopy is recommended for measuring the height of rectal neoplasms but appears to be performed in only a minority of patients. Our aim was to compare endoscopic and radiological measurement of rectal tumour location with a focus on differentiation between mid and high rectal cancer.Medical records of 66 rectal cancer patients were reviewed. Tumour location defined at colonoscopy (66 patients), rigid proctosigmoidoscopy (20 patients) and endorectal ultrasound (35 patients) was recorded. Rectilinear and curvilinear methods were used to estimate the distance between the lower tumour level and the anal verge on sagittal CT or MR images (66 patients). Agreement, intra- and inter-observer variation of radiology-based measurements were -assessed using intra-class correlation (ICC) and within-subject coefficient of variation (WSCV).Tumour location was performed at rigid proctosigmoidoscopy in 30% of patients. Intra- and inter-observer agreement for radiology-based measurements were high. Tumour location using the rectilinear method or proctosigmoidoscopy was similar on average, for a difference of only 0.34 cm (SD 2.0 cm, p = 0.330), although agreement was -moderate (ICC = 0.54, WSCV = 16.7%). Measurements based on colonoscopy and the curvilinear radiological method were -characterized by a systematic overestimation of the location, increasing with tumour height.Radiology-based measurement of the lower tumour level is a reproducible alternative for tumour location at rigid or flexible endoscopy. Its validity should be further assessed.

OBJECTIVES Intestinal metaplasia is associated with gastric carcinomas, in particular intestinal-type carcinomas. According to the literature, intestinal metaplasia, especially the sulphomucin-rich incomplete type (type IIb or III) can be considered as a precancerous lesion. Intestinal metaplasia is not uncommon in gastric lymphomas, and the purpose of this study was to determine its prevalence and extent, its different subtypes and the distribution of sulphomucin and to compare these findings with those in gastric carcinomas. DESIGN The prevalence and grade of intestinal metaplasia were investigated in surgical specimens from 160 patients with gastric carcinoma (102) [intestinal type (69), diffuse type (33)] and gastric lymphoma (58) [marginal zone cell (29), diffuse large cell (29)]. Intestinal metaplasia is analysed by specific mucin stains. METHODS Intestinal metaplasia was described according to the Updated Sydney system. Using periodic acid-Schiff Alcian Blue pH 2.5 and high iron-diamine/Alcian Blue staining, the intestinal metaplasia was classified (Jass classification) and its sulphomucin content was determined. RESULTS The prevalence and extent of intestinal metaplasia are significantly higher in intestinal-type carcinomas than all other gastric malignancies. Subtyping of intestinal metaplasia is independent of the different types of gastric neoplasia. High sulphomucin positivity in the metaplastic epithelium is only seen in intestinal-type carcinomas, although in a small number of cases (21.5%). CONCLUSION Prevalence, extent and sulphomucin content of intestinal metaplasia are significantly higher in intestinal-type gastric carcinoma compared to diffuse-type carcinoma, marginal zone cell and diffuse large cell lymphomas in the stomach.

Laparoscopic ventral recto(colpo)pexy (LVR) is a minimally invasive, autonomic nerve-sparing technique to treat rectal prolapse syndromes. The position of the mesh on the anterior aspect of the rectum in the rectovaginal septum allows correction of concomitant rectocele and enterocele.Demographic, perioperative, and follow-up data of consecutive patients were analyzed in order to audit our 10-years' experience with the technique.From January 1999 to December 2008, 405 patients (93% female) underwent LVR for internal rectal prolapse (45.9%, n = 186), total rectal prolapse (43%, n = 174) and rectocele or enterocele (11.1%, n = 45). Mean age was 54.6 years (SD 15). The median hospital stay was 4 days (range 2-21). Conversion rate was 2%. There was no postoperative mortality. At a mean follow-up of 25.3 months, recurrence was observed in 4.6% (19 patients). Most often detachment of the mesh at the sacral promontory was found. Late complications occurred in 18% of patients. In five patients, LVR combined with perineotomy was complicated by mesh erosion into the vagina. Mesh erosion was not observed after LVR without perineotomy. Symptomatic improvement was observed in 85% of patients with total rectal prolapse and in 70% of patients with internal rectal prolapse (p0.050). The difference was mainly due to a lesser effect on obstructed defecation symptoms.LVR, with or without perineotomy, appears to be safe and feasible, with relatively low morbidity. Functional outcome data support its efficacy. The indication for LVR in patients with internal rectal prolapse could be optimised.

Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery.Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life.The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re-education (n=7), colonic irrigation (n=2) and sacral nerve stimulation (SNS) (n=6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re-education or SNS. Three studies reported improved quality of life after pelvic floor re-education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS.Conservative therapies such as pelvic floor re-education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence-based conclusions.

Single incision laparoscopy aims to reduce access trauma and facilitate specimen extraction. We report our early experience and describe the learning curve for single-port laparoscopic appendectomy and cholecystectomy as a primer for more advanced single-port laparoscopic procedures.From June 2009 to February 2010, all consecutive patients undergoing elective single-port appendectomy and cholecystectomy at the day surgical centre were included. A prospective database with perioperative data was created.Ten appendectomies and 4 cholecystectomies were done in 13 patients, predominantly males (77%), with a mean age of 45 years and a mean BMI of 23 kg/m2. The mean operative time was 31 minutes and 75 minutes for appendectomy and cholecystectomy, respectively. One extra trocar was placed in the first two cholecystectomies, to improve exposure and allow cholangiography. All patients did well at a median follow-up of 5.8 months and no wound infections, nor incisional hernias were detected.Single-port laparoscopic appendectomy and cholecystectomy is safe and feasible with a short learning curve and has good outcome.

A systematic review was performed to identify differences in surgical technique, postoperative morbidity, length of hospital stay and safety for procedures involving left-sided laparoscopic colectomy with natural orifice specimen extraction.A PubMed search was performed to retrieve studies reporting on left-sided laparoscopic colorectal resection with transrectal specimen extraction. The quality of the different reports was assessed according to the Newcastle-Ottawa Scale. Six studies were included and all but one were cohort studies. Studies on transanal, transvaginal or transcolonic specimen extraction were excluded, as were reports on paediatric surgery.Six papers (including 94 patients) fulfilled the search criteria. The techniques reported were not standardized and this technical heterogeneity hampered pooled analysis. A meta-analysis could also not be performed because of differences in inter-study methods, study population and results. All studies showed, nevertheless, that the technique is feasible with low morbidity and short postoperative hospital stay. No anal dysfunction was reported.To date, the evidence in favour of left-sided laparoscopic colectomy with transrectal specimen extraction is weak (level IV-V). Future clinical research should focus on standardization of the technique. Randomized controlled trials are necessary to show the superiority of this approach with regard to postoperative pain and morbidity, hospital stay, recovery, function and cosmesis.

There have been initiatives to create a European audit project. This paper addresses the issue of differences in data collected by different registries.Patients with rectal cancer treated in 2008 and recorded in quality registries from Belgium, Germany/Poland, Spain and Sweden were analyzed. The comparison included number of patients, gender, age, American Society of Anesthesiology (ASA) classification, preoperative diagnostic and staging procedures, neoadjuvant therapy, surgical treatment and quality of surgery, postoperative complications and adjuvant treatment.The Belgian database consisted of 622 patients, the German/Polish database consisted of 3,393 patients, the Spanish database consisted of 1,641 patients and the Swedish database consisted of 1,826 patients. The percentage of patients in each ASA stage was highly variable. MRI use was highest in Spain and Sweden and very low in Germany/Poland. The percentage of cT4 stage tumours in Sweden was much higher than in all other countries. Sweden recorded the highest percentage of primary metastatic disease (20.3%) and Belgium recorded the lowest (10.2%). Neoadjuvant therapy in different protocols was administered to 41.2% patients in Germany/Poland, to 50.8% in Spain, to 55.2% in Belgium and to 62% in Sweden. Laparoscopic surgery (conversion rate) was performed for cure in 5% (28%) of patients in Sweden, in 20.8% (20.6%) in Spain, in 28.6% (15.2%) in Belgium and in 14.5% (8.9%) in Germany/Poland. The 30-day mortality for anterior resection, abdominoperineal excision and Hartmann's procedure in Sweden, Belgium and Spain was 2.0%, 2.3% and 3.1%, respectively. The German/Polish database reported an in-hospital mortality of 3.2%.A European quality assurance project in rectal cancer is possible only after data collection is standardized.

Diarrhoea with urgency is a debilitating long-term complication of ileal pouch anal anastomosis (IPAA) after a proctocolectomy. Somatostatin analogues are used to control diarrhoea and high-output ostomies. Hence, we designed a prospective, double-blind, crossover trial to explore the efficacy and tolerability of octreotide to reduce diarrhoea in adult patients with IPAA.Patients were randomized to octreotide subcutaneously (SC), 500 μg three times daily (t.i.d.), or matching placebo SC for 7 days. Responders (a reduction in stool frequency of three or more stools per 24-h period and with a reduction in stool frequency of at least 30% after 7 days of treatment compared with baseline; the primary end-point) remained in the same group and nonresponders could cross over to the alternative treatment for 7 days. Open-label octeotide LAR 30 mg was offered to all responders on day 14. Flexible pouchoscopy with biopsies was performed at baseline in all patients and was repeated on days 7 and 14 in patients with pouchitis.Fifteen patients (11 men, median age 52 years), all with ulcerative colitis, were randomized. Three patients were withdrawn for side effects during the blinded phase. Response was achieved by two of 12 and two of 11 patients treated with octreotide or placebo, respectively (including crossover, P = 0.9). The median stool frequency remained stable in both groups [Δoctreotide: 0 (IQR, -4 to 0), Δplacebo: -1 (IQR, -1 to 1), P = 0.45]. Octreotide had no effect on the modified pouch disease activity index (mPDAI), and pouchitis persisted in five of six subjects with pouchitis at onset. One subject received open-label octreotide LAR.Octreotide has no clear beneficial effect on the stool pattern or on pouchitis severity in patients with high stool frequency after IPAA.

Laparoscopic segmental bowel resection and reanastomosis for endometriosis with colorectal wall invasion can be associated with high complication rates. This study was performed to test the hypothesis that this high complication rate can be prevented and combined with a good clinical outcome, following a multidisciplinary surgical approach.A retrospective cohort study of all patients with deep endometriosis and colorectal invasion treated by CO₂ laser laparoscopic radical excision between September 2004 and September 2006 (n = 45) to document the clinical outcome: complications, recurrence and fertility (life table analysis), pain, quality of life (QOL) and sexual function.No immediate major post-operative complications requiring surgical reintervention were recorded. Gynaecological pain (P0.0001), sexual function (P0.03) and QOL (P0.0001), improved significantly after a median follow-up period of 27 (range: 16-40) months. Although five patients (11%) had a surgical reintervention, histologically proven recurrent endometriosis was observed in only two (4%), with a cumulative endometriosis recurrence rate of 2.2 and 4.4% after 1 and 3 years, respectively. Thirteen of 28 patients who wanted to become pregnant conceived after surgery. One patient delivered twice. These 14 pregnancies were achieved spontaneously (n = 9) or after IVF (n = 5). The cumulative pregnancy rate was 47% after 3 years.Pain, sexual function and QOL improved significantly and were associated with a good fertility rate and a low complication and recurrence rate after a CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.

With the introduction of single-port surgery, expected advantages are improved cosmesis, decrease of pain and shorter length of stay. The aim of this study was to compare early outcomes of single-port colectomy with those of conventional laparoscopic colectomy.All consecutive patients undergoing single-port colectomy between January and June 2010 were identified from a prospective database. They were matched for age, sex, body mass index, American Society of Anesthesiology score and type of resection with patients who had conventional laparoscopic colectomy. All perioperative data, analgesic requirement, pain scores and inflammatory response were compared using the Wilcoxon signed-rank and McNemar tests.Fourteen patients [five men, nine women; median age (interquartile range) 56 (30-73) years, body mass index (interquartile range) 22 (20-24) kg/m2] underwent single-port colectomy and were matched with patients who had conventional laparoscopic colectomy. Median operating times, estimated blood loss, pain scores, analgesic requirement, inflammatory response and length of hospital stay were similar. Median increase in incision length was significantly higher in the single-port group (P=0.004), but maximal incision length for specimen extraction was comparable. There were no anastomotic leaks, wound infections or 30-day readmissions.In a case-matched setting with a small sample size, single-port laparoscopic colectomy has comparable outcomes to conventional laparoscopic colectomy.

Cellular swelling of erythrocytes exposed to Me 2 SO during freezing and thawing may lead to hemolysis upon dilution of the cryoprotectant with pure electrolyte buffer. Excessive cell swelling is effectively avoided by exposing the RBC to the nonpenetrating sorbitol after thawing and before dilution. Due to the initial reduction in volume by sorbitol, cell swelling upon dilution may not cause hemolysis particularly with concentrations of 0.05 to 0.15 M of sorbitol in the diluting electrolyte buffer. Membrane damage incurred during freezing and thawing is particularly pronounced with the older red cell population, while with the younger population membrane integrity can be preserved to an optimal degree.

We present a case of miliary tuberculosis diagnosed 15 months after infliximab treatment despite negative screening for previous exposure to Mycobacteria on skin PPD and chest X-ray. This case shows that--although screening for TB with a skin PPD and a chest X-ray should be performed in all patients--this is not 100% effective and may be a problem in patients on concomitant immunosuppression. The clinical course of this patient further shows that in a patient treated with anti-TNF antibodies who's condition does not improve one should always be aware of the possibility of a tuberculosis infection. Even though tuberculosis is usually not rapidly fatal, the disease may show a fulminant course in immunocompromised patients.

Radiologists are involved at all stages of the treatment of patients with rectum cancer: in the preoperative staging, in the diagnosis of postoperative complications, in the detection of recurrent or metastatic disease during follow-up, in the monitoring of the therapeutic effect of palliative therapy. PROCARE is a Belgian national project to improve outcome in all patients with rectum cancer. Guidelines were made by a multidisciplinary workgroup and are available on the web. Decentralised implementation of guidelines is organised by the scientific and professional organisations. It is planned that a central review committee of radiologists, delegated by the Royal Belgian Society of Radiology, will survey the quality of preoperative staging. Overall quality of care will be assured by registration in a specific national database starting in 2006. Participating teams will receive annual feedback. Radiologists should provide data on cTNM staging and cCRM. Differentiation between cT2 and cT3, cN0 and cN+, and measurement of the cCRM in mm are crucial as they have a relevant impact on treatment strategy. While spiral abdominal CT is adequate for cM staging, high-resolution MRI is highly recommended and, in fact, a necessity for locoregional staging because its adequacy is superior to that of CT-scan and EUS. However, EUS is mandatory when local excision is considered, i.e. for cT1N0 lesions.

Division of the rectum following total mesorectal excision (TME) using intracorporeal stapling devices is technically difficult due to their width and limited roticulation. More than one cartridge is often required and resultant wedging of the stump may be associated with an appreciable leak rate.Three-dimensional reconstruction was performed of CT and MRI images from the lower abdomen of six patients undergoing laparoscopic TME using the Amira software environment. The stapling device was virtually reconstructed by in-house developed software, superimposed over the point of division of the rectum and the site of skin entry identified.The 45 degrees angulation of available roticulating stapling devices precludes perpendicular division of the rectum following laparoscopic TME. The optimal angulation for transverse rectal stapling varied between 62 degrees and 68 degrees .A roticulating stapler with minimum angulation of 65 degrees would achieve transverse division of the rectum following laparoscopic TME.

To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM).In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months.Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P0.0001). Healing time was shorter after PPH (P0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM.Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haemorrhoidal disease, needing further surgery.

The optimal treatment for patients with nonparasitic splenic cysts is controversial. This study aimed to evaluate the clinical outcome of patients treated for a symptomatic splenic cyst, and to define a surgical strategy.Spleen-preserving surgery (9 laparotomies and 6 laparoscopies) was performed for a primary cyst in six patients and a secondary cyst in nine patients. The median follow-up time was 37.5 months. Partial splenic resection was performed for eight patients and cyst decapsulation for seven patients.Cyst recurrence was observed in four patients after decapsulation of a primary splenic cyst, as compared with none after resection. Postoperative complications were encountered only after laparotomy (5/9). The median hospital stay was 3.5 days (range, 2-5 days) after laparoscopy, as compared with 9 days (range, 5-14 days) after laparotomy.Symptomatic splenic cysts should be treated laparoscopically. For patients with recurrent or suspected primary splenic cysts, laparoscopic partial splenectomy is preferable. For other cases, a laparoscopic decapsulation is advocated.

Some young and active patients requiring abdominoperineal resection for rectum cancer ask for an alternative of an abdominal colostomy. We analysed the results after a combination of a perineal colostomy and antegrade continence enemas (ACE). Fifteen patients have been operated between 1999 and 2004. Follow-up wassix months in 12 patients with a mean of two years and with a maximum of 55 months. The QLQ-C30 (version 3) and CR 38 questionnaires of the EORTC have been used to evaluate quality of life aspects. Five out of 15 patients presented complications: infection of the caecal conduit (2), small bowel obstruction (1), prolapse of the perineal colostomy (1), eventration (1), urologic complications (2). ACE are still used by all patients. The volume needed was 400 ml and duration of irrigation was 30 minutes (15-45 minutes). The median score for faecal incontinence was 0 ; faecal pseudocontinence was obtained by 7/12 patients. The scores for all aspects of functioning were excellent, as well as the score for body image. The general health status and quality of life were estimated at 75% from normal value. The procedure is simple and can be performed in one operative session. A perineal colostomy with ACE seems to be a valuable and less expensive alternative for an abdominal colostomy, and certainly for total anorectal reconstruction.

Background Dynamic graciloplasty (DGP) is an option in patients with end-stage faecal incontinence. The aim of this retrospective multicentre study was to assess early and late outcome after DGP. Methods Sixty consecutive patients with congenital (14) or acquired (40) faecal incontinence or who had undergone total anorectal reconstruction (six) underwent DGP. Patients were followed up for a median of 48 (range 13–117) months. Results There were no deaths; 75 complications that required 61 reoperations were observed in 44 patients. Loss of muscle stimulation occurred in 22 patients, more frequently after direct nerve stimulation. Evacuation difficulties occurred in 12 patients. Overall, DGP failed in 27 patients, of whom seven had stoma construction. At follow-up, continence to solid stool without stoma was obtained in 47 of 60 patients, although 26 required use of antegrade continence enemas or other measures. Functional outcome was related to the presence of a functioning DGP and a short delay (less than 50 days) of muscle training after transposition. Conclusion DGP is a major operation with a high morbidity rate; it requires experience and early muscle training. The outcome after DGP should be compared prospectively with that after implantation of an artificial sphincter or other less expensive alternatives.

By temporarily suppressing the immune response, the anti-tumour necrosis factor agent, infliximab, may increase the risk of peri-operative complications.To test this hypothesis for intestinal resection in a cohort of 313 Crohn's disease patients treated with infliximab. Forty received one or more infusions prior to intestinal resection (31/40 within 12 weeks).The post-operative events of these patients were compared with those of a control group (infliximab naive) of 39 patients adjusted for age, gender and surgical procedure. Early (10 days) and late (3 months) major or minor complications were identified.The incidence of early minor (15.0% vs. 12.8%) and major (12.5% vs. 7.7%) and late minor (2.5% vs. 5.1%) and major (17.5% vs. 12.8%) complications and the mean hospital stay after surgery (10.3 +/- 4.0 days vs. 9.9 +/- 5.5 days) were similar in both groups. A trend towards an increased early infection rate was found in infliximab pre-treated patients (6 vs. 1; P = 0.10), but more patients in this group received corticosteroids and/or immunosuppressives (29 vs. 16 patients; P0.05).The use of infliximab before intestinal resection does not prolong the hospital stay and does not increase the rate of post-operative complications.

In the last decade our understanding of pelvic floor function and dysfunction has improved significantly. A more rational diagnostic and therapeutic approach is now possible for the group of patients with constipation due to obstructed defecation (OD).The review is based on a literature search using the PubMed database focusing mainly on recent literature addressing the subject.Obstructed defecation occurs in about 7% of the adult population. Different pathophysiological mechanisms, either functional or anatomical, eventually lead to OD. Different tests (defecography, balloon evacuation test, manometry, electromyography, colonic transit time measurementmanometry) play an important role to quantify the problem. These tests are not without problems as abnormal results are also found in asymptomatic controls. Also, there is poor agreement between different tests and a poor correlation with symptomatology. Thus, for most syndromes conservative treatment including biofeedback is appropriate. Surgery can yield excellent results in selected cases.Validation of scoring systems and quantitative tests is still needed. More uniform and strict criteria for anismus should be applied to make therapeutic approaches comparable. Appropriate selection of patients for surgery is the key to success.

To summarise the magnitude and mechanisms of surgeon-related variability in the outcome after radical resection for rectal cancer and to present a solution and targets.A review of the literature, consultation of the "Guidelines for the management of colorectal cancer" published by the Association of Coloproctology of Great-Britain and Ireland, and analysis of data from the database of the Belgian Ministry of Health, RIZIV-INAMI, on radical resection for rectal cancer in Belgium during the years 1995-1997.The proportion of abdominoperineal excision of the rectum (APER) varies between 23-58% in specialised centres and 43-57% general practice. In Belgium the APER rate for rectal cancer located between 4 and 16 cm above the anal verge is 50% with an overall in-hospital mortality of 3.5%; both APER rate and postoperative mortality are lower in university than in community hospitals. Most studies observe an effect of specialisation, reducing mortality with a factor of 2.5-3. The magnitude of surgeon-related variability in the oncological outcome has been well documented indicating that the impact of the surgeon-factor is considerably larger than that of adjuvant therapy. When comparing subspecialised with general surgeons, relative risk factors of 0.3-0.8 are reported for local recurrence rate, and 0.7-0.8 for disease free survival.Inter-surgeon variability is to be related with surgical skill and adequate implementation of recent diagnostic and therapeutic methods. Guidelines and centralisation are appropriate concepts, but do not guarantee improved quality of care. The targets are an APER rate of40% with an operative risk of2%, a local recurrence rate of10% and a disease free survival of70%. External audit is essential, but subspecialty training is a prerequisite and the surgeon is not the only factor to be audited.

The management of anal fistulas in patients with IBD continues to be extremely challenging and, indeed, somewhat frustrating. Despite a global closure rate of about 75%, all patients should be informed about the risk of infection, early failure, eventual temporary disfunctioning stoma and the possibility of late recurrence (about 15%). Closure of a RVF in Crohn's disease should not be considered an easy undertaking, especially in patients with several Crohn localisations. The technique can be adapted to the local situation. Construction of a temporary stoma is not mandatory. However, stoma construction seems to be beneficial when extensive perianal or recto-vaginal dissection including eventual tissue interposition is required. Advancement flaps are an attractive surgical alternative for the management of all anal transsphincteric fistulas, also in Crohn's disease, because sphincter architecture and function are well preserved. Improved medical treatment and the changed approach from conservative to reparative surgery may well have resulted in a decreased need or at least in a delay of the need for a proctectomy. Although the surgical principles of advancement flap techniques are sound, these techniques have not been used for many decades. Skills needed, problematic approach, suboptimal quality of local tissues have contributed to its selective use and to the absence of prospective randomised studies.

The aim of the study was to evaluate the use of positron emission tomography with [18F]-fluorodeoxyglucose (FDG-PET) in patients with unexplained rising carcinoembryonic antigen (CEA) in the postoperative surveillance of colorectal cancer. 50 consecutive patients with elevated CEA levels and a completely normal (n=31) or equivocal (n=19) conventional diagnostic work-up (CDW) were retrospectively selected. All PET images were reviewed with full knowledge of the CDW. The gold standard consisted of histology, or clinical follow-up of more than 1 year. Recurrent disease was established in 56 lesions in 43 patients. On a patient-based analysis, the sensitivity of FDG-PET was 34/43 (79%), and the positive predictive value 34/38 (89%). In 14/50 patients (28%), the FDG-PET findings led to a surgical resection with curative intent. On a lesion-based analysis, FDG-PET detected 42/56 lesions (sensitivity: 75%), the positive predictive value was 79% (42/53). These results demonstrate that FDG-PET can have a clear impact on patient management in patients with an unexplained elevation in CEA levels.

Anal fistulae do not heal spontaneously without surgery. Knowledge of anorectal anatomy and function, and diligent examination frequently requiring anaesthesia are prerequisites for adequate assessment, classification and treatment of the pathology. Fistulography, endoanal ultrasound and MRI of the anorectum may have additional diagnostic value with therapeutic impact in complex and recurrent fistulae. Parks' classification is most useful because it is the best guide for surgical therapy. In the modern treatment of trans- or suprasphincteric fistula in ano fast or slow division of any part of the striated perianal musculature is to be avoided in order to prevent anal incontinence.

In order to select a species for drug absorption studies of ester prodrugs and to identify a possible absorption window with low esterase activity and hence increased absorption of the ester prodrug, the esterase activity was investigated in homogenates from various intestinal segments of different species. p-Nitrophenyl acetate and tenofovir disoproxil [bis(POC)-PMPA] were used as substrates for esterases. p-Nitrophenyl acetate is a model substrate for esterase activity, while tenofovir disoproxil (fumarate salt) is an ester prodrug of the potent antiviral nucleoside phosphonate analogue tenofovir. As esterase-mediated degradation during transepithelial transport may be a limiting factor for its oral absorption, targeting the prodrug to a region of the intestine with lower esterase activity may lead to an increase in oral absorption of the prodrug. The results obtained with p-nitrophenyl acetate and tenofovir disoproxil showed both a site-specific (duodenum > or = jejunum > ileum > or = colon) and species-dependent (rat > man > pig) degradation in intestinal homogenates. Degradation of tenofovir disoproxil in homogenates from Caco-2 monolayers (0.016+/-0.003 nmol. s(-1). mg protein(-1)) was low compared to its degradation in homogenates from human ileum (0.177+/-0.052 nmol. s(-1). mg protein(-1)). Rat ileum appears to be a suitable model to evaluate the influence of esterase activity on the oral absorption of the ester prodrug, as the degradation rate for tenofovir disoproxil (0.245+/-0.054 nmol. s(-1). mg protein(-1)) in rat ileum was similar to degradation in human ileum. The results also suggest that colon targeting may be a useful strategy to reduce the esterase-mediated degradation of ester prodrugs, hence resulting in a possible increase in their oral absorption.

Fistula formation after restorative proctocolectomy poses a challenge to the surgeon and sometimes can lead to the excision of the pouch. A 21-year-old female patient developed an ileal J-pouch-sacral fistula with abscess and osteomyelitis of the sacrum, more than three years after the pouch construction for ulcerative colitis. Two months prior to this event, the patient had a single and transient episode of pouchitis. The role of pouchitis in the aetiopathogenesis of the fistula is unclear. To our knowledge, the late development of such a fistula has not been reported previously.

This paper provides some basic insights in economic evaluation and costing methodology by means of illustrations in the field of laparoscopic surgery. Some general methodological aspects are discussed, as well as their impact on the calculation of both societal and hospital costs of medical interventions. First, Health Care Technology Assessment is described, and several techniques of economic evaluation in health care are situated in this area. Two fundamental concepts in costing analysis are discussed : opportunity costs and marginal (or incremental) analysis. Furthermore, it is argued that in designing an economic analysis, sufficient attention should be given to delineating the alternative treatment options and to determining the perspective from which the study is performed (patient, hospital, insurer, society,...). Subsequently, it is argued that all price and wage data for activities performed within a certain period should apply to the same time period. Finally, in order to facilitate overview, re-calculation and interpretation of cost data, it is advised to distinguish fixed from variable costs. Different categories of societal costs are described, as well as a number of methodologies for their evaluation. In calculating hospital costs, the costs of all different resources used (e.g. buildings, equipment, staff, materials) must be identified precisely. The issues of annuitising initial investment expenses, calculating operating and maintenance costs, and allocating labour and overhead costs are discussed. Finally, it is argued that, in all studies, it should be investigated whether the results of the economic analysis are robust to the models' assumptions, by means of sensitivity analysis. This paper provides a practical toolkit for medical doctors, to allow a correct understanding and critical analysis of economic literature in the field of laparoscopic surgery.

The complications during and following endoscopic excision of deep endometriosis were analysed. The data of 225 excisions performed in 212 women had been collected prospectively into a database immediately following surgery and during the follow-up visit. The data confirmed the association of severe pelvic pain and deep endometriosis, severe pelvic being the only indication for surgery in 67, 78 and 76% of women with type I (n = 99), type II (n = 55) and type III (n = 71) lesions respectively. They confirmed that type II and type III were the largest lesions and that they were found predominantly in revised American Fertility Society (AFS) class II. The duration of surgery decreased with expertise (P0.01), but increased when deeper or larger lesions were excised (P0.0001) and when cystic ovarian endometriosis was also present (P0.001). Excision was clinically judged to be complete in 94, 96 and 85% of women with type I, II or III lesions respectively. In order to achieve this, part of the bowel wall had to be resected in 6.3% and part of the posterior vaginal fornix in 13.6% of cases. This risk was associated mainly in type II or III lesions and with larger lesions (P = 0.001). This was not considered as a complication, since all lesions could be repaired endoscopically and since follow-up was uneventful. Complications were one ureter lesion and seven late bowel perforations with periotonitis. Our data did not permit the evaluation as to whether medical pretreatment could improve completeness of surgery or decrease the risk. They revealed, however, that in six of seven women with type III lesions--in whom excision was judged to be complete--no pretreatment had been given and that luteinizing hormone releasing hormone (LHRH) agonist treatment decreased the volume of type II lesions (P = 0.04). In conclusion, complete endoscopic excision could be performed in over 90% of women with deep endometriosis, but required bowel surgery in over 6% of cases. Ureter lesions were rare, but postoperative bowel perforations with periotonitis occurred in 2-3% of cases. Medical pretreatment is advocated since LHRH agonist treatment was shown to shrink the deep endometriotic lesion.

Two groups of patients referred for suspicion of acute appendicitis were compared to evaluate the accuracy of preoperative ultrasonography (US) and surgical decision-making. In one retrospective study, US was performed by trainees using a 3.5 MHz probe (219 patients). In the second prospective study, US was performed by a resident radiologist using a 5 MHz probe (144 patients). US accuracy rose from 65% to 90%, especially due to an improved negative predictive value (from 52% to 92%). The positive predictive value of US was 89%. The sonographically adjusted clinical decision to operate was correct in 85%. Thus, all patients with positive US should be operated. In contrast, clinical judgment must prevail in case of negative US findings in order to prevent surgical delay in about 11%. The negative laparotomy rate decreased by 5% only. This is probably due to the limited influence of negative US findings on surgical decision. US is to be recommended in all patients suspected for acute appendicitis when performed with an appropriate probe by an experienced ultrasonographist. However, it may not, on it self, reduce the rate of unnecessary operative procedures.

The presence of intraluminal viable exfoliated tumour cells has been demonstrated in patients with colorectal cancer. Several non-randomised studies found a significant reduction of the recurrence rate after the intraoperative luminal instillation of cytotoxic agents, as compared with "historical" patient series. Antiseptic solutions, e.g. sodium hypochlorite and povidone-iodine, were reported to be "cancericidal" for exfoliated cancer cells in vitro. A survey held among Belgian surgeons practising colorectal cancer surgery revealed that 78% of them never use any agent during surgery. Only a minority performs pre-resectional luminal instillation-mostly to treat the distal (low) anastomotic level: 14% in patients with rectal cancer and 7% in patients with colon cancer. About 8% of the surgeons only perform peritoneal/pelvic lavage at the end of the procedure. This is in strong contrast with surgical practice in the UK. It seems reasonable to advocate intra-operative pre-resectional bowel washouts with cytotoxic agents besides other measures to avoid recurrence, e.g. the no touch isolation technique with early division of the vascular supply, wide excision of the mesenterium, avoidance of iatrogenic tumour perforation, "en bloc" resection if adjacent organs are invaded, adjuvant radio- and chemotherapy.

The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.

It has been suggested that the combination of etoposide, leucovorin and 5-fluorouracil (ELF) is very active in the treatment of advanced gastric cancer in elderly patients. The aim of this study was to confirm the efficacy and to investigate the toxicity of the ELF-regimen in patients of all ages. Thirty patients with advanced gastric adenocarcinoma were treated with leucovorin (300 mg/m2), etoposide (100 mg/m2) and 5-FU (500 mg/m2) for 3 consecutive days every 4 weeks in a phase II study. Reevaluation of measurable disease was done after 3 cycles. A partial response was shown in 8 (27%) patients. An improvement of the Karnofsky Performance Status was observed in 10 (33%) patients. The mean survival amounted to 8 months (range 2-24). Toxicity was mild. No grade 4 toxicity nor chemotherapy-related mortality were observed. It is concluded from this phase II study that the ELF-regimen is an active palliative treatment for advanced gastric cancer, with mild toxicity.

Local excision has to be classified as either indeterminate or non curative from a surgical oncological point of view. It seems to be an acceptable procedure for well differentiated, exophytic/polypoid pT1 lesions of less than 3 cm in diameter, providing the resection margins are tumour-free. For all other lesions radical surgery is to be preferred, unless the patient is unfit for major surgery or refuses an eventual permanent colostomy. Complete local excision followed by radiation therapy may become a valuable alternative for well differentiated, small pT2 lesions, but results are too preliminary. If radical surgery is indicated, the distal clearance margin (to be measured in the fresh, unstretched specimen) may be reduced to 2 cm if taking more distal tissue would jeopardise the anal sphincter. The mesorectum should be completely cleared in patients with low- or mid-rectal cancer. A benefit of excision of the internal iliac nodes in rectal cancer below the peritoneal reflection has not been demonstrated. Low anterior resection is the operation of choice for carcinoma with its lower border above 8 cm from the anal verge. Complete, restorative rectum excision with colo-anal anastomosis (CAA) is the option for tumours with their lower border between 6 and 8 cm from the anal verge if an acceptable margin of distal clearance is obtained. Rectal cancer with its distal border below 6 cm usually requires abdominoperineal rectum excision, although restorative proctectomy with CAA may be a valuable alternative in selected patients with small, well or moderately differentiated tumours.

The relationship between symptoms and manometric data was studied in incontinent patients. Conventional anal manometry, the rectal saline infusion test and the balloon-retaining test were performed in 27 control subjects (M:8, F:19; mean age: 47 yr) and in 40 incontinent patients (M:5, F:35; mean age: 49 yr). The correlation coefficient between the clinical degree of continence/incontinence and the maximum anal basal tone, squeeze pressure and the pressure increment during squeeze was -0.74, -0.74 and -0.57, respectively. Discriminatory values of40 mmHg for maximum basal pressure and92 mmHg for squeeze pressure could identify continent patients with 96%, and incontinent patients with 88% accuracy. The uncontrollable evacuation of a balloon, progressively filled with water at 60 ml/min, before the maximum tolerable sensation level was reached, was related to the degree of clinical incontinence. Also the maximum retained volume and the interval between the first sensation volume and the maximum retained volume ("perceived rectal capacity") were related to the clinical symptoms: r = -0.72 and -0.71, respectively. The balloon-retaining test proved to be superior to the rectal saline infusion test for the determination of the severity of incontinence. The saline infusion test, however, was found to be more adequate to identify minor defects of continence. Thus, the manometric assessment of anorectal continence should consist of routine anal manometry, the rectal saline infusion test and the balloon-retaining test. Some important clinical implications are discussed.

Both hepatic ischemia and chemotherapy are effective in the treatment of carcinoid liver metastases, but their effectiveness is often limited, partial and transient. It has been shown that, during intermittent occlusion of the hepatic artery with a surgically implanted occluder, no revascularisation from collaterals occurs. We studied the feasibility, the side-effects, the response to tumour measurements and hormonal excretions of a combined treatment of repeated hepatic ischemia and 5-Fluorouracil and Streptozotocin-administration in carcinoid liver metastases.

Widespread alterations of the gut autonomic nervous system have been described in Crohn's disease. Immunohistochemistry shows that these alterations are associated with the expression of major histocompatibility (MHC) class II antigens (HLA-DR) on enteroglial cells in the ganglia of the submucous and myenteric plexuses and on the enteroglial sheaths of the nerve extensions. Neuronal cell bodies and extensions do not express MHC class II antigens. The class II expression is associated with the presence of UCHL1-positive T lymphocytes. MHC class II expression can also be found on endothelial cells and vascular smooth muscle cells but not on smooth muscle cells of the muscularis mucosae or propria. The intensity of MHC class II expression on the glial cells of the enteric nervous plexus and on endothelial cells correlates well with the intensity of class II expression on epithelial cells.

The role of the distal stomach in gastric emptying was studied. Ten patients with proximal gastric vagotomy (PV) and 10 age-matched patients with Roux-en-Y gastro-jejunostomy (R-Y) were compared with 10 healthy controls. Gastric emptying of solids and liquids was determined by the use of Tc-99m SC scrambled eggs and In-111 DTPA. In PV, gastric emptying of both solids and liquids was delayed; the prolongation with solids was mainly accounted for by an abnormal lag phase. In R-Y patients, no lag phase was observed, and the solid emptying curve pattern was characterized by early rapid emptying followed by very slow emptying. Both the solid and liquid phases were prolonged. The lag phase is affected by proximal vagotomy and is mainly determined by the distal stomach, which appears to be essential for normal emptying.

Patients presenting diffuse, advanced, established peritonitis due to free perforation of the colon, in whom an adequate abdominal debridement cannot be obtained in one operative session were selected. We report results of the planned relaparotomy approach in 44 patients as compared with an historical series of 9 analogous patients treated by on demand exploratory relaparotomies. Planned relaparotomies were performed every 2 days until the abdominal cavity became macroscopically clean. This approach significantly reduced both the incidence of multiple organ failure and the mortality rate (31%) as compared with the regimen of on demand relaparotomy. The mortality rate in the planned relaparotomy group is related to the age of the patient and to the nature of peritonitis. Faecal peritonitis carries a higher mortality rate than purulent peritonitis. The mortality rates of severe postoperative peritonitis and advanced primary peritonitis were not significantly different. Surgery for severe, diffuse peritonitis has to be prompt, moderately aggressive and repeated if necessary. Therefore, planned relaparotomies have a place in the treatment of selected patients presenting diffuse, advanced, established peritonitis.

A method is presented for the identification and analysis of constipation due to difficult evacuation of rectal content. This condition--which has not been elucidated by former techniques--was identified in 5 out of the 19 constipated patients by this new method. Disturbed defecation was characterized by prolonged evacuation of the simulated stool and the greater work performed during this process. The cause of this phenomenon was the paradox movement of the pelvic floor, i.e. contraction instead of relaxation. The results' highlight: the excessive straining can induce a neuromuscular damage to the pelvic floor. The clinical importance of this method lies in the clarification of the principle, that the therapy of this condition must be initiated as early as possible.