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Background Rectal prolapse is a disease presentation with a prevalence of about 1%, mainly affecting older women. It usually presents with symptoms of rectal mass, rectal bleeding, fecal incontinence or constipation, with patients frequently feeling socially isolated as a result. Perineal rectosigmoidectomy is associated with lesser morbidity and mortality than the abdominal procedure, but with a much higher recurrence rate. Therefore, this technique is mainly suitable for the frail elderly patient. Specific outcomes in an elderly population have been described in only a few studies. We evaluated the morbidity, mortality, recurrence rate and functional results after this procedure related to age. Methods All patients who underwent a perineal rectosigmoidectomy over a 10-year period in two tertiary referral centers were included in the study. American Society of Anesthesiology (ASA) grade, pre- and postoperative symptoms, pathology-reported post-fixation specimen length, length of in-patient stay, 30-day morbidity/mortality, and recurrence were measured. Results A total of 45 patients underwent a perineal rectosigmoidectomy. Forty-three (95%) were female, with a median age of 82.0 years (IQR 70.5–86.5), ASA grade III and median follow-up of 20 months (range 8.5–45.5 months). Half of the cohort was over 80 years old. Significant symptomatic relief was achieved, predominantly the resolution of rectal mass (8.9% vs. 60.0% preoperatively), fecal incontinence (15.6% vs. 46.7%) and constipation (4.4% vs. 26.7%). The median length of stay was 6 days, while morbidity occurred in 14 patients (31.1%) and recurrence occurred in 6 patients (13%). There were no deaths within 30 days of the procedure and outcomes were comparable in the Conclusions Perineal rectosigmoidectomy is safe for older patients with greater comorbidities resulting in good functional results and is associated with low morbidity and mortality.

Faecal incontinence and rectal prolapse remain common clinical conditions, where treatment and management remain a challenge for the patient and the clinician. The two conditions comprise an area where no two patients could be managed the same, each needing personalized tailored approach. Over the past decade there has been an influx of interest in managing patients with these very debilitating conditions, both in terms of surgical techniques, device, subspecialist training and multi-disciplinary approach. These coupled with reduction in stigma traditionally associated with the two conditions have encouraged patients to come forward and the health professional to develop a focused interest.

AIM: Permacol™ collagen paste (Permacol™ paste) is an acellular cross-linked porcine dermal collagen matrix suspension for use in soft tissue repair. The use of Permacol™ paste in the filling of anorectal fistula tract is a new sphincter-preserving method for fistula repair. The MASERATI100 study was a prospective, observational clinical study with the objective to assess the efficacy of Permacol™ collagen paste for anal fistula repair in 100 patients.METHOD: Patients (N=100) with anal fistula were treated at ten European surgical sites with a sphincter-preserving technique using Permacol™ paste. Fistula healing was assessed at 1, 3, 6, and 12 months post-treatment, with the primary endpoint being healing at 6 months. Faecal continence and patient satisfaction were surveyed at each follow-up; adverse events (AEs) were monitored throughout the follow-up.RESULTS: At 6 months post-surgery, 56.7% of patients were healed, and the percentage healed was largely maintained, with 53.5% healed at 12 months. 29.0% of patients had at least one AE, and 16.0% of patients had one or more procedure-related AE. Most AEs reported were minor and similar to those commonly observed after fistula treatment, and the incidence of serious adverse events was low (4.0% of patients). Regardless of treatment outcome, 73.0% of patients were satisfied or very satisfied with the procedure.CONCLUSION: Permacol™ paste provides a promising sphincter-preserving treatment for anal fistulas with minimal adverse side-effects. This article is protected by copyright. All rights reserved.

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

Aim Incomplete colonoscopy occurs in 8-10% of attempted examinations. An incomplete colonoscopy is usually followed by radiological evaluation of the large bowel to complete colonic assessment. Patients then found to have >1cm polyps represent a significant management dilemma. This study describes our experience using laparoscopy to facilitate complete colonoscopy and polypectomy in patients with fixed angulation and the success of subsequent colonoscopies. Methods All patients from 2008 to 2012 with an incomplete colonoscopy due to fixed angulation and polyps detected by subsequent imaging underwent standard laparoscopy with colonic mobilisation by division of adhesions to facilitate direct vision. Completion of colonoscopy and polypectomy, intra-operative complications, post-operative morbidity and successful standard follow-up colonoscopy were studied. Results Twelve patients underwent the procedure. Complete colonoscopy to caecum was successful in all, with a mean of 2.1 polyps per patient (range 1-5) and a mean polyp size of 22mm. One iatrogenic enterotomy was repaired immediately, with no sequelae. Ten patients have since undergone colonoscopy under sedation with complete colonic evaluation possible in nine of the patients.. Conclusion Laparoscopic assisted colonoscopy allows safe polypectomy in patients with incomplete colonoscopy without the need for segmental resection. This less invasive procedure yields recovery times similar to colonoscopy alone, avoiding the morbidity of a segmental resection with the added benefit of successful routine colonoscopy in the future. This article is protected by copyright. All rights reserved.

Extramammary Paget disease (EMPD) is a rare perineal neoplasia associated with a high rate of local recurrence. Surgical excision is the standard treatment; however, this has high rates of post-operative morbidity in combination with potentially mutilating results. Previous literature has demonstrated good response with imiquimod 5% cream in patients with vulval EMPD, yet its effectiveness in primary perianal disease is unknown. We describe the case of a 40-year-old woman presenting with EMPD of the perianal region, providing detailed histological and pictoral evidence of its response to topical imiquimod 5% cream over a 16-week period, which initially resulted in remission prior to metastatic lymph node recurrence. This case demonstrates the potential for topical imiquimod cream to avoid major surgery and its associated complications in patients presenting with EMPD of the perianal region. We discuss the current evidence for treating this rare condition with medical therapy, how this case adds to current literature and possible future directions.

Introduction NHS Tayside serves a population of 400,000, with 2 acute hospitals providing emergency and elective surgery. The Inflammatory Bowel Disease (IBD) service cares for approximately 2000 patients. At present, there is no detailed record of the number of bowel resections performed locally for IBD. We retrospectively reviewed the number of operations performed over a 6 year period. Method Caldicott Guardian approval was granted. The Pathology Dept. archives were searched using SNOMED codes to generate a list of patients undergoing bowel resection between 1 st January 2008 and 31 st December 2013. The patient–s CHI number was used to search the electronic patient record to view pathology reports, clinical letters and paper casenotes if required. Verified resections for Crohns Disease (CD), Ulcerative Colitis (UC), Indeterminate Colitis (IC) had details about the resection recorded; elective vs emergency, open vs laparoscopic, and the operating surgeon was noted. Results Over the study period there were 307 resections in 263 patients, with a mean of 51 resections/yr (median 50.5). The proportions of elective and laparoscopic procedures increased over time from 50% to 58% and 16% to 34% respectively. 182 resections (165 patients) were for CD, 114 resections (89 patients) for UC, and 11 resections (9 patients) were classified as IC. Of the resections for CD; 59% were female, median age 38 (IQ range 25–55). 91/182 procedures were emergency, and 140/182 were open. The number of resections/yr for CD decreased over time, peaking at 37 in 2009, falling to 27 in 2013. Of the resections for UC; 55% were male, median age 49.5 yrs (IQ range 31–65). 45/114 were emergency, and 74/114 were open. The median number of resections/yr was 18.5, with peaks of 25, 24 in 2010, 2013 respectively. Colorectal surgeons accounted for 10/16 operators performing elective surgery and undertook 96% of resections, compared to 12/29 and 70% for emergency surgery. Over the study period, the median number of emergency resections per surgeon was: 7.5 (range 3–22) and 2 (range 1–5) for colorectal and non-colorectal respectively. For elective surgery the median was 8 (range 4–45) per colorectal surgeon. Conclusion In NHS Tayside, the trend is towards more elective, laparoscopic surgery for IBD. The number of resections/yr for CD is falling. Elective surgery is almost exclusively performed by colorectal surgeons, and the majority delivered by a small group. 30% of emergency resections are performed by non-colorectal surgeons who resect IBD infrequently. Disclosure of interest None Declared.

Introduction Historically, the treatment of anal fistulas has required a compromise between successful fistula healing and preservation of continence. The aim of this study (NCT01624350) is to evaluate clinical outcomes of anal fistulas treated with Permacol™ collagen paste. Method Patients (N = 98) with magnetic resonance imaging-confirmed intersphincteric or transsphincteric anal fistulas, cryptoglandular primary or recurrent, from ten European sites were treated with Permacol™ collagen paste. Fistula healing, adverse events, and patient satisfaction were assessed up to 12 months post-surgery, with fistula healing at 6 months confirmed by clinical assessment as the primary endpoint. Cox regression analyses were performed to determine if patient or fistula characteristics correlate with better healing. Results The median follow-up was 26.8 weeks (range 0.1–62.4 weeks), with 87 and 46 patients having healing data at 6 months and 12 months, respectively. At 6 months follow-up, 51 (58.6%) patients exhibited a clinically-healed anal fistula, including 20/35 (57.1%) that were recurrent at the time of treatment. At 12 months, 19 (41.3%) patients were healed. Younger patients and those with evidence of expulsion or leakage of Permacol™ collagen paste were the only variables associated with a significantly increased risk of failure (p = 0.0017 and p = 0.0068, respectively). A total of six serious adverse events were reported, four of which (perianal abscess, n = 2; non-healing fistula tract, n = 1; complex regional pain syndrome, n = 1) were possibly related to the device and/or the procedure. Continence was preserved throughout the follow-up. At their last visit, over 70% of patients reported being satisfied or very satisfied with their operation, indicating that some patients were satisfied even though their fistula did not heal. Conclusion These preliminary results demonstrate that Permacol™ collagen paste is a well-tolerated, sphincter-sparing technique for the treatment of anal fistulas with low morbidity. Disclosure of interest P. Giordano Grant/Research Support from: Covidien, Consultant for: Covidien, Speaker Bureau of: Covidien, P. Sileri Grant/Research Support from: Covidien, S. Buntzen Grant/Research Support from: Covidien, Speaker Bureau of: Medtronic, A. Stuto Grant/Research Support from: Covidien, J. Nunoo-Mensah Grant/Research Support from: Covidien, L. Lenisa Grant/Research Support from: Covidien, B. Singh Grant/Research Support from: Covidien, Speaker Bureau of: Covidien, O. Thorlacius-Ussing Grant/Research Support from: Covidien, B. Griffiths Grant/Research Support from: Covidien, D. Ziyaie Grant/Research Support from: Covidien, Speaker Bureau of: Covidien.

The number of hospital beds per head of population has fallen by more than 2% a year since 1980.1 Levels of bed occupancy have risen during this period.1 Appropriate bed occupancy is crucial to the NHS, as occupancy rates exceeding 85% in acute hospitals are associated with problems in dealing with emergency and elective admissions.1 We aimed to develop a valid instrument for the objective assessment of appropriateness of occupancy of surgical beds. We drew potential criteria for the instrument from analyses of the medical notes of 200 general surgical inpatients. We chose criteria such that if any one was met we could judge that particular day of surgical care to be appropriate. We shortlisted the criteria after each had been scrutinised by a consultant physician or surgeon of the relevant subspecialty, and we structured them into an instrument. We modified the instrument (box) after a pilot study of 40 bed days. We conducted a validation study on 100 bed days in a general surgical unit with an interest in colorectal surgery. We selected 10 bed days once a week for 10 weeks by using computer generated random numbers. Two …

s / International Journal of Surgery 12 (2014) S13eS117 S29 Conclusions: The data shows that higher values of faecal calprotectin correspond to an increased degree of mucosal inflammation. 0602: APER IN A DISTRICT GENERAL HOSPITAL e SHOULD WE BE DOING MORE? Adenike Odeleye, Simran Choudary, Henry Lee, O.A. Lalude, S. Vivekanandan. Princess Alexandra Hospital, London, UK. Introduction: Appropriate surgical management of rectal cancer is crucial to survival. The decision for abdominoperineal excision of rectum (APER) goes against surgical inclinations to engineer an anastomosis with a low anterior resection (LAR). Inappropriately optimistic surgical decisions are known to foster high local recurrence rates and poor overall survival. We aimed to inspect the APER rate and outcomes of patients with rectal cancer in our centre. Methods: A prospectively maintained departmental database was interrogated to determine all patients undergoing AR or APER between 1/1/ 2008-31/12/2010. Recurrence was identified on post-operative CT scans at 2 years. Results: Patients underwent an APER 16% n1⁄414 or AR 84% n1⁄469. The overall average age was 71. Male to Female ratio 1.6:1. One of the LAR patients had local recurrence (1.5%) at 2years whilst there was no evidence of recurrence in the APER group. Distant metastases were identified in 14% of the APER group vs. 5.9% in the LAR group. Nil significant difference in recurrence rates (P-value

s / International Journal of Surgery 11 (2013) 589e685 622 ABSTRACTS 0401: PERINEAL RECTOSIGMOIDECTOMY FOR RECTAL PROLAPSE Himanshu Wadhawan, Sacha Koch, Dorin Ziyaie, Kenneth Campbell. NHS Tayside, Dundee, Scotland, UK. Introduction: Rectal prolapse is a condition that mainly occurs in older women. We evaluated the morbidity, mortality, recurrence rate and functional results of the perineal rectosigmoidectomy. Methods: All patients who underwent a perineal rectosigmoidectomy between 2004-2011 in a tertiary referral center were included. Symptoms pre-and postoperatively, length of specimen after fixation in formalin, postoperative hospital stay, 30 days morbidity and mortality, and recurrence were determined. Results: Forty-one patients were included. Forty (93% female) with a mean age of 78 13 years. Eight (20%) had a recurrence of a previous perineal rectosigmoidectomy. In most patients, Altemeier procedure performed only in two patients Delorme procedure. Symptoms were: 69% feeling of rectal mass, 24% painful defecation, 50% faecal incontinence, 31% constipation, 19% rectal bleeding. Postoperatively, these symptoms were present in 24%, (p