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Anal fissure has a very large number of treatment options. The choice is difficult. To assist in this choice, presented herein is a summary of a systematic review and meta-analysis of all published treatments for anal fissure that have been studied in randomized controlled trials up through 2016. The review is divided into those studies that compared two or more surgical procedures and those that had at least one arm that was nonsurgical. Studies were further categorized by the specific interventions and comparisons. The outcome assessed was the inverse of sustained cure of the fissure, i.e., treatment failure. In addition, the harms of treatment assessed were headache and anal incontinence. Risk of bias was assessed for each study and the strength of the evidence of each comparison was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). A total of 148 eligible trials were found and assessed, 31 in the surgical group (2606 patients) and 117 in the nonsurgical group (9456 patients). There were 14 different operations described in the surgical group and 29 different nonsurgical treatments in the nonsurgical group along with partial lateral internal sphincterotomy (LIS). There were 61 different comparisons. Of these, 47 were reported in two or fewer studies, usually with quite small populations. The largest single comparison was glyceryl trinitrate (GTN) versus control with 19 studies. GTN was more effective than control in terms of sustained cure (odds ratio = 0.68; 95% confidence interval = 0.63–0.77) but the quality of evidence was very poor due to severe heterogeneity and risk of bias due to inadequate clinical follow-up. The only comparison to have a high GRADE quality of evidence was a subgroup analysis of LIS versus any medical therapy, with outcome of treatment failure (0.12; 0.07–0.21) and mild incontinence (4.41; 1.97–9.87) assessed after at least 6 months from surgery. There were 12 studies in this analysis, the medical therapy being GTN in 6, Botox in 5, and calcium channel blocker (CCB) in 1. Most of the other analyses were downgraded in GRADE due to imprecision, i.e., too few or too small studies, and significant heterogeneity in almost all other comparisons with more than six studies. LIS is superior to nonsurgical therapies in achieving sustained cure of fissure with an increased risk of mild incontinence, usually meaning flatus. CCBs were more effective than GTN and had less risk of headache, but with only a low quality of evidence. Anal incontinence, once thought to be a frequent risk with LIS, was found in various subgroups in this review to have a risk between 3.4 and 4.4%. Among the surgical studies, manual anal stretch (Lord procedure) performed worse than LIS in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open LIS and closed LIS appear to be equally efficacious, with a moderate GRADE quality of evidence. Most other GRADE evaluations of procedures were low to very low, due mostly to imprecision.

The benefit of adding oral antibiotic prophylaxis (OA) to intravenous prophylaxis (IV) in elective colorectal surgery to prevent surgical site infection (SSI) and whether the benefit of OA requires a mechanical bowel cleansing (MBP) are assessed in a systematic review. Meta-analyses compare randomized trials of IV versus IV plus OA, both with MBP; OA versus IV plus OA, both again with MBP; OA plus IV in studies randomizing patients to MBP or no MBP; and IV versus IV plus OA in patients with no MBP. MEDLINE, EMBASE, and the Cochrane Library were searched for eligible studies from 1965 to April 1, 2020. The outcome assessed was SSI, superficial and deep, but not organ space. For each included study, risk of bias was assessed using the Cochrane Risk of Bias tool version 1. For each comparison, meta-analysis was performed from data from eligible studies to obtain a summary effect and heterogeneity using RevMan. Sensitivity analyses were performed excluding studies of poor quality. Certainty of evidence was assessed using GRADE for each comparison. Sixty-one studies published in 1971–2020 from 55 publications reporting 12,297 patients were eligible for inclusion. A total of 36 studies compared IV to OA plus IV with MBP. The risk ratio (RR) and 95% confidence interval (CI) for SSI with oral and IV vs. IV alone are 0.47, 0.40–0.56. The RR in 19 studies for IV plus OA versus OA alone is 0.48, 0.38–0.62. The RR for OA plus IV with MBP versus without MBP in 5 studies is 1.17, 0.84–1.64. The RR for OA plus IV versus IV alone when no bowel prep was used in two studies is 0.36, 0.18–0.72. RRs were similar in sensitivity analyses. The GRADE is high for the first two comparisons, moderate for the 3rd, and low for the 4th due to imprecision and heterogeneity. Combined OA and IV is superior to either alone in preventing SSI. The certainty of evidence is such that further research is unlikely to alter this relationship when MBP is used. In randomized trials of MBP, OA plus IV shows no benefit from MBP versus no MBP. The last comparison shows in just two studies that as in the first meta-analysis, but in the absence of MBP, combined OA plus IV is also superior to IV alone.

This protocol for a Cochrane Review is out of date. The authors have abandoned it.

Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review. Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI. Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54–1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76–1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79–1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes. There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.

Anal fissure has a very large number of treatment options. The choice is difficult. In an effort to assist in that, choice presented here is a systematic review and meta-analysis of all published treatments for anal fissure that have been studied in randomized controlled trials. Randomized trials were sought in the Cochrane Controlled Trials Register, Medline, EMBASE and the trials registry sites clinicaltrials.gov and who/int/ictrp/search/en. Abstracts were screened, full-text studies chosen, and finally eligible studies selected and abstracted. The review was then divided into those studies that compared two or more surgical procedures and those that had at least one arm that was non-surgical. Studies were further categorized by the specific interventions and comparisons. The outcome assessed was treatment failure. Negative effects of treatment assessed were headache and anal incontinence. Risk of bias was assessed for each study, and the strength of the evidence of each comparison was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. One hundred and forty-eight eligible trials were found and assessed, 31 in the surgical group and 117 in the non-surgical group. There were 14 different operations described in the surgical group and 29 different non-surgical treatments in the non-surgical group along with partial lateral internal sphincterotomy (LIS). There were 61 different comparisons. Of these, 47 were reported in 2 or fewer studies, usually with quite small patient samples. The largest single comparison was glyceryl trinitrate (GTN) versus control with 19 studies. GTN was more effective than control in sustained cure (OR 0.68; 95% CI 0.63–0.77), but the quality of evidence was very poor because of severe heterogeneity, and risk of bias due to inadequate clinical follow-up. The only comparison to have a GRADE quality of evidence of high was a subgroup analysis of LIS versus any medical therapy (OR 0.12; CI 0.07–0.21). Most of the other studies were downgraded in GRADE due to imprecision. LIS is superior to non-surgical therapies in achieving sustained cure of fissure. Calcium channel blockers were more effective than GTN and with less risk of headache, but with only a low quality of evidence. Anal incontinence, once thought to be a frequent risk with LIS, was found in various subgroups in this review to have a risk between 3.4 and 4.4%. Among the surgical studies, manual anal stretch performed worse than LIS in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open LIS and closed LIS appear to be equally efficacious, with a moderate GRADE quality of evidence. All other GRADE evaluations of procedures were low to very low due mostly to imprecision.

Among the techniques investigated to reduce the risk of surgical wound infection or surgical space infection (SSI) in patients having colorectal surgery are topical application of antimicrobials (antibiotics and antiseptics) to the open wound or immediately after closure. The aim of the present study was to perform a systematic review of the literature on those treatments, with the exception of antibiotic ointments applied to closed skin, which are adequately assessed elsewhere, and a meta-analysis.Only randomized trials of patients having only colorectal surgery were included in this review. Studies were sought in MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, Clinical Trials.gov, and the World Health Organization Internet clinical trials register portal. In addition, reference lists of included studies and other published reviews were screened. Meta-analysis was performed for all included studies and subgroup analyses done for each individual intervention. Risk of bias was assessed for each included study, paying particular attention to the preoperative antibiotic prophylaxis used in each study. Sensitivity analyses were done to investigate heterogeneity of the analyses, excluding those studies with a significant risk of bias issues. Absolute risk reduction (RR) was calculated. The overall quality of the evidence for each individual intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and was classified as high, moderate, low or very low.A total of 30 studies are included in this review with 5511 patients, 665 of whom had SSI. The interventions included: 10 studies of gentamicin impregnated sponge or beads wound inlays, 4 studies of chlorhexidine impregnated suture, 11 studies of direct wound lavage or powder application or injection of antibiotics before closure, 4 studies of ionized silver dressing applied to the closed skin, and 1 study of vitamin E oil applied to the open wound. All but one study used preoperative antibiotic prophylaxis in addition to topical procedures, although, in some studies, the systemic antibiotic prophylaxis was not the same between groups or varied significantly from the recommended guidelines. Use of gentamycin sponge did not decrease SSI (RR 0.93, 95% CI 0.75-1.16; low-quality evidence) even after including only the studies of abdominal wounds (RR 1.02, 95% CI 0.80-1.30; low-quality evidence). However, sensitivity analysis excluding studies at high risk of bias decreased the heterogeneity and increased the effect of the prophylaxis for all wounds (RR 0.5, 95% CI 0.33-0.78; low-quality evidence) and for abdominal wounds only (RR 0.38, 95% CI 0.20-0.72; moderate-quality evidence). Chlorhexidine impregnated suture showed no effect on SSI (RR 0.79, 95% CI 0.56-1.10; low-quality evidence) and an increased efficacy after sensitivity analysis (RR 0.42, 95% CI 0.22-0.79; low-quality evidence). Antibiotic lavage showed a significant decrease in SSI (RR 0.45, 95% CI 0.26-0.79; low-quality evidence) which increased after sensitivity analysis (RR 0.33, 95% CI 0.15-0.72; moderate-quality evidence). Application of silver dressing to the closed wound resulted in a decrease of SSI (RR 0.55, 95% CI 0.35-0.85; moderate-quality evidence). The one study of topical vitamin E oil applied to the open wound showed a significant risk reduction (RR 0.22, 95% CI 0.05-0.98; low-quality evidence).Each of these interventions appears to be effective in decreasing SSI, but the number of studies for each is small and the quality of evidence is very low to moderate. Within the various outcomes of GRADE assessment, even a moderate classification suggests that further studies may well have very different results.. No randomized trials exist of combinations of two or more of the above interventions to see if there is a combined effect. Future studies should make sure that the antibiotic used preoperatively is uniform within a study and is consistent with the current guidelines. Deviation from this leads to a significant heterogeneity and risk of bias.

Background Surgeons who perform laparotomy have a number of decisions to make regarding abdominal closure. Material and size of potential suture types varies widely. In addition, surgeons can choose to close the incision in anatomic layers or mass ('en masse'), as well as using either a continuous or interrupted suturing technique, of which there are different styles of each. There is ongoing debate as to which suturing techniques and suture materials are best for achieving definitive wound closure while minimising the risk of short- and long-term complications. Objectives The objectives of this review were to identify the best available suture techniques and suture materials for closure of the fascia following laparotomy incisions, by assessing the following comparisons: absorbable versus non-absorbable sutures; mass versus layered closure; continuous versus interrupted closure techniques; monofilament versus multifilament sutures; and slow absorbable versus fast absorbable sutures. Our objective was not to determine the single best combination of suture material and techniques, but to compare the individual components of abdominal closure. Search methods On 8 February 2017 we searched CENTRAL, MEDLINE, Embase, two trials registries, and Science Citation Index. There were no limitations based on language or date of publication. We searched the reference lists of all included studies to identify trials that our searches may have missed. Selection criteria We included randomised controlled trials (RCTs) that compared suture materials or closure techniques, or both, for fascial closure of laparotomy incisions. We excluded trials that compared only types of skin closures, peritoneal closures or use of retention sutures. Data collection and analysis We abstracted data and assessed the risk of bias for each trial. We calculated a summary risk ratio (RR) for the outcomes assessed in the review, all of which were dichotomous. We used random-effects modelling, based on the heterogeneity seen throughout the studies and analyses. We completed subgroup analysis planned a priori for each outcome, excluding studies where interventions being compared differed by more than one component, making it impossible to determine which variable impacted on the outcome, or the possibility of a synergistic effect. We completed sensitivity analysis, excluding trials with at least one trait with high risk of bias. We assessed the quality of evidence using the GRADEpro guidelines. Main results Fifty-five RCTs with a total of 19,174 participants met the inclusion criteria and were included in the meta-analysis. Included studies were heterogeneous in the type of sutures used, methods of closure and patient population. Many of the included studies reported multiple comparisons. For our primary outcome, the proportion of participants who developed incisional hernia at one year or more of follow-up, we did not find evidence that suture absorption (absorbable versus non-absorbable sutures, RR 1.07, 95% CI 0.86 to 1.32, moderate-quality evidence; or slow versus fast absorbable sutures, RR 0.81, 95% CI 0.63 to 1.06, moderate-quality evidence), closure method (mass versus layered, RR 1.92, 95% CI 0.58 to 6.35, very low-quality evidence) or closure technique (continuous versus interrupted, RR 1.01, 95% CI 0.76 to 1.35, moderate-quality evidence) resulted in a difference in the risk of incisional hernia. We did, however, find evidence to suggest that monofilament sutures reduced the risk of incisional hernia when compared with multifilament sutures (RR 0.76, 95% CI 0.59 to 0.98, I2 = 30%, moderate-quality evidence). For our secondary outcomes, we found that none of the interventions reduced the risk of wound infection, whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.99, 95% CI 0.84 to 1.17, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.16, 95% CI 0.85 to 1.57, moderate-quality evidence), closure method (mass versus layered, RR 0.93, 95% CI 0.67 to 1.30, low-quality evidence) or closure technique (continuous versus interrupted, RR 1.13, 95% CI 0.96 to 1.34, moderate-quality evidence). Similarily, none of the interventions reduced the risk of wound dehiscence whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.78, 95% CI 0.55 to 1.10, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.55, 95% CI 0.92 to 2.61, moderate-quality evidence), closure method (mass versus layered, RR 0.69, 95% CI 0.31 to 1.52, moderate-quality evidence) or closure technique (continuous versus interrupted, RR 1.21, 95% CI 0.90 to 1.64, moderate-quality evidence). Absorbable sutures, compared with non-absorbable sutures (RR 0.49, 95% CI 0.26 to 0.94, low-quality evidence) reduced the risk of sinus or fistula tract formation. None of the other comparisons showed a difference (slow versus fast absorbable sutures, RR 0.88, 95% CI 0.05 to 16.05, very low-quality evidence; mass versus layered, RR 0.49, 95% CI 0.15 to 1.62, low-quality evidence; continuous versus interrupted, RR 1.51, 95% CI 0.64 to 3.61, very low-quality evidence). Authors' conclusions Based on this moderate-quality body of evidence, monofilament sutures may reduce the risk of incisional hernia. Absorbable sutures may also reduce the risk of sinus or fistula tract formation, but this finding is based on low-quality evidence. We had serious concerns about the design or reporting of several of the 55 included trials. The comparator arms in many trials differed by more than one component, making it impossible to attribute differences between groups to any one component. In addition, the patient population included in many of the studies was very heterogeneous. Trials included both emergency and elective cases, different types of disease pathology (e.g. colon surgery, hepatobiliary surgery, etc.) or different types of incisions (e.g. midline, paramedian, subcostal). Consequently, larger, high-quality trials to further address this clinical challenge are warranted. Future studies should ensure that proper randomisation and allocation techniques are performed, wound assessors are blinded, and that the duration of follow-up is adequate. It is important that only one type of intervention is compared between groups. In addition, a homogeneous patient population would allow for a more accurate assessment of the interventions.

Background Clostridium difficile is recognized as a frequent cause of antibiotic-associated diarrhea and colitis. Objectives The aim of this review is to investigate the efficacy of antibiotic therapy for C. difficile-associated diarrhea (CDAD). Search methods MEDLINE (1966 to March 24, 2010), EMBASE (1980 to March 24, 2010), Cochrane Central Register of Controlled Trials and the Cochrane IBD/FBD Review Group Specialized Trials Register were searched using the following search terms: "pseudomembranous colitis and randomized trial"; "Clostridium difficile and randomized trial"; "antibiotic associated diarrhea and randomized trial". Selection criteria Only randomized, controlled trials assessing antibiotic treatment for CDAD were included in the review. The following outcomes were sought: initial resolution of diarrhea; initial conversion of stool to cytotoxin and/or culture negative; recurrence of diarrhea; recurrence of fecal evidence of CDAD; patient response to cessation of prior antibiotic therapy; emergent surgery; and death. Data collection and analysis Three authors independently assessed abstracts and full text articles for inclusion. The risk of bias was independently rated by two authors. For dichotomous outcomes, relative risks (RR) and 95% confidence intervals (CI) were derived from each study and summary statistics obtained when appropriate, using a fixed effects model, except where significant heterogeneity was detected, at which time a random effects model was used. Main results Fifteen studies (total of 1152 participants) with CDAD were included. Nine different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin and fidaxomicin (OPT-80). Most of the studies were active comparator studies comparing vancomycin with other antibiotics. The risk of bias was rated as high for 12 of 15 included studies. Patients with severe CDAD were often excluded from the included studies. In the only placebo-controlled trial vancomycin was found to be superior to placebo for treatment of CDAD for initial symptomatic cure. Initial symptomatic cure was achieved in 41% of vancomycin patients compared to 4% of placebo patients (1 study; 44 patients; RR 9.00; 95% CI 1.24 to 65.16). Vancomycin was significantly superior to placebo for initial bacteriologic response. Initial bacteriologic response was achieved in 45% of vancomycin patients compared to 4% of placebo patients (1 study; 44 patients; RR 10.00; 95% CI 1.40 to 71.62). The results of this study should be interpreted with caution due to the small number of patients and high risk of bias. No statistically significant differences in efficacy were found between vancomycin and metronidazole, vancomycin and fusidic acid, vancomycin and nitazoxanide, or vancomycin and rifaximin. No statistically significant differences in efficacy were found between metronidazole and nitazoxanide or metronidazole and fusidic acid. Vancomycin was significantly superior to bacitracin for initial bacteriologic response. Initial bacteriologic response was achieved in 48% of vancomycin patients compared to 25% of bacitracin patients (2 studies; 104 patients; RR 0.52; 95% CI 0.31 to 0.86). Teicoplanin, an antibiotic of limited availability and great cost, was significantly superior to vancomycin for initial bacteriologic response and cure. Initial bacteriologic response was achieved in 62% of vancomycin patients compared to 87% of teicoplanin patients (2 studies; 110 patients; RR 1.43; 95% CI 1.14 to 1.81). Bacteriologic cure was achieved in 45% of vancomycin patients compared to 82% of teicoplanin patients (2 studies; 110 patients; RR 1.82; 95% CI 1.19 to 2.78). These results should be interpreted with caution due to the small number of patients and the high risk of bias in the two studies in the pooled analysis. Teicoplanin was significantly superior to metronidazole for initial bacteriologic response. Initial bacteriologic response was achieved in 71% of metronidazole patients compared to 93% of teicoplanin patients (1 study; 59 patients; RR 0.76; 95% CI 0.60 to 0.98). This result should be interpreted with caution due to the small number of patients and high risk of bias in the study. Only one study investigated synergistic antibiotic combination, metronidazole and rifampin, and no advantage was demonstrated for the drug combination. This result should be interpreted with caution due to the small number of patients and high risk of bias in the study. Adverse events including surgery and death occurred infrequently in the included studies. There was a total of 18 deaths among 1152 patients in this systematic review. Among the studies that commented on the cause of mortality the deaths were attributed to underlying disease rather than CDAD or antibiotic treatment. One study reported a partial colectomy after failed CDAD treatment. Authors' conclusions Current evidence leads to uncertainty whether mild CDAD needs to be treated. The studies provide little evidence for antibiotic treatment of severe CDAD as many studies excluded these patients. Considering the two goals of therapy: improvement of the patient's clinical condition and prevention of spread of C. difficile infection to other patients, one should choose the antibiotic that brings both symptomatic cure and bacteriologic cure. A recommendation to achieve these goals cannot be made because of the small numbers of patients in the included studies and the high risk of bias in these studies, especially related to dropouts. Most of the active comparator studies found no statistically significant difference in efficacy between vancomycin and other antibiotics including metronidazole, fusidic acid, nitazoxanide or rifaximin. Teicoplanin may be an attractive choice but for its limited availability (Teicoplanin is not available in the USA) and great cost relative to the other options. More research of antibiotic treatment and other treatment modalities of CDAD is required.

Although the incidence of Clostridium difficile-associated diarrhea in the general population has increased dramatically over the past decade, an even greater rate of infection exists in patients with inflammatory bowel disease. Susceptibility in this population is likely inherent to the pathophysiology and treatment of these diseases. C. difficile infection can cause serious complications and death. Consequently, early diagnosis and initiation of effective antibacterial therapy is imperative. This article evaluates treatment recommendations for an initial episode of C. difficile infection in patients with inflammatory bowel disease based on the current guidelines and a Cochrane systematic review.

Covered in this chapter are complications of perineal proctectomy, rectal mucosectomy (Delorme), anal circlage (Thiersch), and stapled perineal proctectomy (TRANSTAR or PSP). The relative risk of each complication is not presented as it is impossible to calculate from the cited case reports and series. Rather atentin is drawn to their existence so that they might be recognized should they occur.

Background Constipation is a common clinical problem. Lactulose and Polyethylene Glycol (PEG) are both commonly used osmotic laxatives that have been shown to be effective and safe treatments for chronic constipation. However, there is no definitive data as to which provides the best treatment. Objectives To identify and review all relevant data in order to determine whether Lactulose or Polyethylene Glycol is more effective at treating chronic constipation and faecal impaction. Search strategy We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of lactulose and polyethylene glycol in the management of faecal impaction and chronic constipation. Selection criteria Studies were included if they were randomised controlled trials which compared lactulose with polyethylene glycol in the management of chronic constipation. Data collection and analysis Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0) and analysed using Cochrane MetaView. Main results In the present meta-analysis, we considered for the first time all ten randomised controlled trials so far performed. The ten trials enrolled a total of 868 participants and were conducted between 1997 and 2007. The trials were conducted in six different countries. Participant age ranged from 3 months to 70 years. Adults only were recruited for 4 studies. Five trials reported stool frequency per week. Singularly taken, all showed that PEG resulted in a higher stool frequency per week when compared with Lactulose. Two trials reported form of stool on the Bristol Stool Scale, both studies reported a higher Bristol Stool Score when using PEG compared with lactulose (softer stool). Three trials reported relief of abdominal pain. Two favoured PEG in this outcome; one found Lactulose and PEG to be comparable in this outcome. Three trials reported on use of additional products, all favoured PEG as requiring less use of additional products. Authors' conclusions The findings of our work indicate that Polyethylene glycol is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products. On subgroup analysis, this is seen in both adults and children, except for relief of abdominal pain. Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation. Plain Language Summary Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation. Constipation is a common clinical problem, encompassing much more than reduced stool frequency. In this review we compared two commonly used osmotic laxatives, Lactulose and Polyethylene Glycol (PEG). The findings of our work indicate that PEG is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products. This is seen in both adults and children. Only exception is for relief of abdominal pain, where PEG is better than lactulose in children, but not in adults (no difference is seen). We conclude that Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation.

Some reports have associated iron with cancer risk, particularly of the colorectum. This review will focus on the human studies that have investigated this association. Comparative studies were sought in which people with and without colorectal neoplastic lesions, either cancers or adenomatous polyps, were assessed for iron exposure. Iron exposure variables included dietary iron intake, iron vitamin supplementation, body iron stores as measured by ferritin or transferrin saturation, and gene status for hereditary hemochromatosis. Medline was searched for published reports using the key words iron, cancer, colon, rectum, ferritin, transferrin, and hemochromatosis. In addition, the Cochrane Library was searched for relevant studies and several authors were contacted to investigate their awareness of unpublished studies. Studies were categorized by study design and ranked for quality of innovation in design, sample size, and thoroughness of iron status ascertainment. Thirty-three studies were reviewed in 26 publications. Of the larger studies, approximately three-quarters supported the association of iron, in all three strata of exposure, with colorectal neoplasia risk. Because iron is broadly supplemented in the American diet, the benefits of iron supplementation need to be measured against the long-term risks of increased iron exposure, one of which may be increased risk of colorectal cancer.

Background Complete (full-thickness) rectal prolapse is a lifestyle-altering disability that commonly affects older people. The range of surgical methods available to correct the underlying pelvic floor defects in full-thickness rectal prolapse reflects the lack of consensus regarding the best operation. Objectives To assess the effects of different surgical repairs for complete (full-thickness) rectal prolapse. Search methods We searched the Cochrane Incontinence Group Specialised Register up to 3 February 2015; it contains trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) as well as trials identified through handsearches of journals and conference proceedings. We also searched EMBASE and EMBASE Classic (1947 to February 2015) and PubMed (January 1950 to December 2014), and we specifically handsearched theBritish Journal of Surgery (January 1995 to June 2014), Diseases of the Colon and Rectum (January 1995 to June 2014) and Colorectal Diseases (January 2000 to June 2014), as well as the proceedings of the Association of Coloproctology meetings (January 2000 to December 2014). Finally, we handsearched reference lists of all relevant articles to identify additional trials. Selection criteria All randomised controlled trials (RCTs) of surgery for managing full-thickness rectal prolapse in adults. Data collection and analysis Two reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The four primary outcome measures were the number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, number of patients with faecal incontinence and number of patients with constipation. Main results We included 15 RCTs involving 1007 participants in this third review update. One trial compared abdominal with perineal approaches to surgery, three trials compared fixation methods, three trials looked at the effects of lateral ligament division, one trial compared techniques of rectosigmoidectomy, two trials compared laparoscopic with open surgery, and two trials compared resection with no resection rectopexy. One new trial compared rectopexy versus rectal mobilisation only (no rectopexy), performed with either open or laparoscopic surgery. One new trial compared different techniques used in perineal surgery, and another included three comparisons: abdominal versus perineal surgery, resection versus no resection rectopexy in abdominal surgery and different techniques used in perineal surgery. The heterogeneity of the trial objectives, interventions and outcomes made analysis difficult. Many review objectives were covered by only one or two studies with small numbers of participants. Given these caveats, there is insufficient data to say which of the abdominal and perineal approaches are most effective. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation. Laparoscopic rectopexy was associated with fewer postoperative complications and shorter hospital stay than open rectopexy. Bowel resection during rectopexy was associated with lower rates of constipation. Recurrence of full-thickness prolapse was greater for mobilisation of the rectum only compared with rectopexy. There were no differences in quality of life for patients who underwent the different kinds of prolapse surgery. Authors' conclusions The lack of high quality evidence on different techniques, together with the small sample size of included trials and their methodological weaknesses, severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Longer follow-up with current studies and larger rigorous trials are needed to improve the evidence base and to define the optimum surgical treatment for full-thickness rectal prolapse.

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Medical therapy for anal fissure is designed to relax the internal anal sphincter, much as is done by sphincterotomy, but reversibly, and thus avoiding long standing minor incontinence. The effectiveness and future of this approach is assessed. Publications were sought in Medline using the search terms: anal fissure randomized, and all articles screened for inclusion. Randomized controlled trials that had at least one arm involving medical therapy for anal fissure were chosen, as were systematic Cochrane reviews of these articles and the quantitative assessment of therapeutic effectiveness reported. In addition, the newer therapies being developed are listed, most of which have not yet been subjected to randomized trials, so their effectiveness is unknown. Lastly, the major problems still facing medical therapy for anal fissure are listed in hope that trials will be conducted that will specifically address these questions. Currently medical therapy for anal fissure is effective in achieving long term cure, whether glyceryl trinitrate ointment, botulinum toxin injection, or calcium channel blockers given orally or topically, but only marginally so. They are far less effective than surgery.

Purpose: To determine factors associated with the development of urinary and fecal incontinence in nursing homes. Design and methods: Residents of Wisconsin skilled nursing facilities reported in the Wisconsin annual nursing home survey continent to both urine and stool in 1992 were re-assessed 1 year later for the development of urinary and/or fecal incontinence. Independent variables were elements of the HCFA minimum data set found to be significantly associated with incontinence in cross-sectional surveys of Wisconsin nursing home residents. Results: Dementia and advancing age were consistently associated with the development of incontinence, but the strongest associations were impairment of activities of daily living and the use of patient restraints. Implication: Adjusting for the major reasons to apply patient restraint: dementia, blindness, arthritis and stroke, along with other risk factors for incontinence, the use of patient restraints is the most significant cause for the development of incontinence in nursing homes.

Nursing home residence is by far the most prominent association with fecal incontinence, with a prevalence approaching 50%. In one major survey, urinary incontinence was the greatest risk factor for developing fecal incontinence, and fecal incontinence was the greatest risk factor for developing urinary incontinence. Immobility, dementia, and the use of physical restraints were also important risk factors. Specific diseases associated with fecal incontinence include diabetes, multiple sclerosis, Parkinson's disease, stroke, and spinal cord injury. The surgical procedures lateral internal sphincterotomy for anal fissure, fistulotomy, and ileal pouch reconstruction can result in fecal incontinence. Children who are born with congenital abnormalities, such as imperforate anus, often experience soiling for many years. Future studies to determine the prevalence and etiology of fecal and urinary incontinence will need to first define these conditions and eliminate referral bias. Epidemiologic investigations of both disorders should be performed jointly because the conditions are so often comorbid.

PURPOSE: Primary repair of penetrating colon injuries is an appealing management option; however, uncertainty about its safety persists. This study was conducted to compare the morbidity and mortality of primary repair with fecal diversion in the management of penetrating colon injuries by use of a meta-analysis of randomized, prospective trials. METHODS: We searched for prospective, randomized trials in MEDLINE (1966 to November 2001), the Cochrane Library, and EMBase using the terms colon, penetrating, injury, colostomy, prospective, and randomized. Studies were included if they were randomized, controlled trials that compared the outcomes of primary repair with fecal diversion in the management of penetrating colon injuries. Five studies were included. Reviewers performed data extraction independently. Outcomes evaluated from each trial included mortality, total complications, infectious complications, intra-abdominal infections, wound complications, penetrating abdominal trauma index, and length of stay. Peto odds ratios for combined effect were calculated with a 95 percent confidence interval for each outcome. Heterogeneity was also assessed for each outcome. RESULTS: The penetrating abdominal trauma index of included subjects did not differ significantly between studies. Mortality was not significantly different between groups (odds ratio, 1.70; 95 percent confidence interval, 0.51–5.66). However, total complications (odds ratio, 0.28; 95 percent confidence interval, 0.18–0.42), total infectious complications (odds ratio, 0.41; 95 percent confidence interval, 0.27–0.63), abdominal infections including dehiscence (odds ratio, 0.59; 95 percent confidence interval, 0.38–0.94), abdominal infections excluding dehiscence (odds ratio, 0.52; 95 percent confidence interval, 0.31–0.86), wound complications including dehiscence (odds ratio, 0.55; 95 percent confidence interval, 0.34–0.89), and wound complications excluding dehiscence (odds ratio, 0.43; 95 percent confidence interval, 0.25–0.76) all significantly favored primary repair. CONCLUSION: Meta-analysis of currently published randomized, controlled trials favors primary repair over fecal diversion for penetrating colon injuries.

Background and Objectives To determine if Americans of African origin (blacks) have less access to colonoscopic polypectomy than Americans of European origin (whites), the rate of carcinoma in situ of the colorectum (CIS), a disease more similar to benign adenoma of the colorectum than invasive cancer in its symptomatology, discovery, and treatment, was determined in the United States from 1973 to 1994. The hypothesis being tested is that CIS will be far less common in blacks than in whites and that rates of CIS should be increasing in whites from 1973 to 1994. Methods CIS and invasive carcinoma of the colorectum incidence data were obtained from Surveillance, Epidemiology, and End Results (SEER) Public Use Files from 1973 through 1994. Rates were age adjusted and proportions determined by division of CIS rates for each subsite by total carcinoma rates, for each year, race, and gender. The colorectum was divided anatomically in this analysis at the junction of the descending and sigmoid colon. Results The relationships between male/female and black/white CIS incidence rates were broadly similar to invasive cancer rates over the 21 years of SEER, demonstrating a white male predominance for distal disease, a black male predominance for proximal disease, and a decline in incidence since 1988. CIS as a proportion of total colorectal cancer increased in all races and genders from 1973 to 1987, but then declined in all groups. Conclusions The majority of CIS is excised by endoscopic resection. Therefore, this might be considered a surrogate population for those individuals who have colonoscopic resection of benign adenomas. It is this latter treatment that has been hypothesized to be the cause for the declining incidence of invasive colorectal cancer. However, data presented herein do not support this hypothesis. J. Surg. Oncol. 1999;71:123–129. © 1999 Wiley-Liss, Inc.

Background and Objectives: A time trend analysis of colorectal cancer (CRC) incidence in the distal colorectum as a proportion of total CRC is presented for the period 1977-1994 as a function of age, to determine the age at which Americans might best be served by screening fiberoptic sigmoidoscopy. Methods: CRC incidence rates were obtained for each anatomic subsite from SEER Public Use Files for 1977, 1986, and 1994. The colorectum was divided anatomically for these analyses at the junction of the descending colon and sigmoid colon. Incidence in the distal colorectum was divided by total CRC incidence to determine the proportion of CRC in that age/race/gender/year cohort located in the distal colorectum. Results: The proportion of distal CRC among African Americans was without a clear trend as they grew older in each of the years of observation and in both genders. However, in whites, with increasing age, the proportion of distal disease declined progressively in both genders, with the greatest decline in 1994. Distal CRC became less prevalent than proximal at about age 72 years in white women and at age 82 in white men in 1994. Conclusions: As the white population becomes older, and for African Americans of all ages, more total colon screening modalities are needed, although at the onset of recommended screening, among 50- to 60-year-olds, fiberoptic sigmoidoscopy would appear efficacious.

BACKGROUND Characteristics that determine the anatomic site within the colorectum where carcinoma is most likely to occur would be useful in choosing optimal modalities for cancer screening and in the study of etiology. The aim of this study was to identify any association of gender, race, or age with colorectal carcinoma in the proximal or distal colorectum. METHODS A descriptive, population-based epidemiologic study was conducted on colorectal carcinoma (CRC) cases identified through the Illinois Tumor Registry. Among CRC patients diagnosed between 1986 and 1991, age at diagnosis (40-90 years), gender, white or African American race, and subsite of CRC location were identified. Incidence rates were determined with demographic data from the 1990 Illinois census. Logistic regression was used to identify significant subsite specific risk factors for CRC. RESULTS During the study period, 38,931 cases of CRC occurred in Illinois among whites and African Americans between the ages of 40 and 90 years. Age, race, and gender were independently significantly associated with both proximal and distal CRC risk (P < 0.0001). The greatest risk for white males was for distal CRC, followed by the risk for African American males of developing CRC in the distal colorectum. African Americans were more likely than whites to develop proximal CRC (odds ratio [OR] = 1.19), whereas whites were more likely to have distal CRC than African Americans (OR = 1.26). Regarding the development of CRC anywhere in the colorectum, male incidence rates adjusted for age and race were greater than rates for females (OR = 1.32 for proximal and 1.68 for distal). CONCLUSIONS The division of the colorectum anatomically in these analyses at the junction of the descending and sigmoid colon, and including the rectum above the anal canal with "distal" CRC, demonstrated a predominance of African Americans among those at risk for proximal colon carcinoma and a predominance of white males among those at risk for distal CRC; these predominances were clearer than in previous reports. These findings may have a role in the selection of optimal CRC screening strategies for each gender or racial group. Cancer 1997; 80:193-7. © 1997 American Cancer Society.

Anorectal fistulas have been the subject of medical and lay literature for over 2,500 years. The term fistula is ascribed to John Arderne (1307–1392) whose classic work on anal fistula is still in print. However, it is important to note that in Ayurvedic medicine, Suhruta (b ~800 bc) described both fistulotomy and fistulectomy as well as the chemical seton using Kshara Sutra. Hippocrates (b ~460 bc) described the use of horsehair (seta) in the treatment of anal fistulas. Fistulas have been written about in many languages and geographical locations throughout the years. The true incidence of anal fistulas is unknown.

We live in an era when at least in the academic and scientific circles, evidence-based medicine has definitely replaced its eminence based counterpart. Readers of medical literature now often evaluate the quality of reported data (e.g., randomized control trials, etc.) and grade the level of evidence presented in the paper searching from level I evidence in support of the published conclusions. The Cochrane database, celebrating its twentieth anniversary this year is replete with such data.

Background Selenium (SE) has been inversely associated with colon cancer risk. Two potential mechanisms of this effect were examined in a rodent short-term carcinogenesis assay: whether dietary SE deficiency altered the initiation aspect of carcinogenesis in the colon, and whether SE altered carcinogen metabolism. Setting Animal laboratory. Subjects 52 Sprague-Dawley rats, divided into a SE diet deficient group (0.002 parts per million; ppm) and a SE sufficient (0.2 ppm) group. Endpoints Weight, serum SE concentration, and karryorhectic index (Kl), which is a measure of acute carcinogen induced nuclear toxicity in the colonic mucosa. Methods After three weeks of acclimation to the diets, eight animals from each dietary group were injected with one of the following: dimethylhydrazine (DMH), a colon specific carcinogen, its metabolite, methylazoxymethanol (MAM), or 0.9% sodium chloride. Twenty-four hours after injection the colons were removed, blood drawn, and the stained colons assayed for nuclear aberrations. Results No weight differences were generated by the dietary variations. Low-dietary SE resulted in serum SE declining markedly in the study period to 6 ng/ml versus 33 ng/ml in the SE sufficient group. Diet alone, and variations in weight gain, did not alter the Kl. Both carcinogens greatly increased the Kl in both the left and right colon. A SE-deficient diet was associated with a higher Kl in both carcinogen groups in the right colon, with statistical significance for both the left and right colon in the MAM injection group. Conclusions Dietary SE deficiency is associated with increased Kl of the colon in MAM treated rats. SE, therefore, has a protective effect in the initiation phase of carcinogenesis.

Screening of the average-risk individual for disease creates a different relationship between practitioner and subject than the normal doctor-patient relationship. Screened individuals are asymptomatic, have a whole range of motivations from denial to neurosis, and, for the most part, derive no benefit from the screen, as they are destined never to contract the disease. Rewards to the few must clearly outweigh the risks to the many. The screening strategy must be economical when applied to a large population, safe, and effective in achieving the ultimate goal, which, in the case of colorectal cancer, is reduction in the mortality rate. Prediagnostic screening of asymptomatic adults over the age of 45 years for primary disease has been shown to fulfill all of these criteria. Postoperative screening of asymptomatic individuals after curative resection of colorectal cancer for recurrence has been shown to fulfill none of them.

This is the protocol for a review and there is no abstract. The objectives are as follows: Our primary objective is to provide readers with a summary of the diagnostic accuracy of US for appendicitis in patients who present with clinically suspected acute appendicitis. Our secondary objectives are to explore the diagnostic accuracy of US for appendicitis in male and female patients, in the paediatric (under 16 years of age) and pregnant patient subgroups and in patients with intermediate clinical suspicion of acute appendicitis or indeterminate diagnostic scores.

BACKGROUND: Selenium deficiency has been associated with cancer risk in several organs. This association was investigated in neoplasia of the colorectum. DESIGN: A case-control study is reported with two patient series, colorectal cancer and colorectal adenomatous polyps, and a control group found to be free of colorectal neoplasia. Diagnosis was determined by colonoscopy and histologic review of suspected neoplasms. Serum drawn at the time of colonoscopy was subsequently assayed for selenium content, and quartiles based on selenium were defined. Crude and adjusted odds ratios with 95 percent confidence intervals for adenoma related to selenium were calculated, controlling for known or suspected risk factors including gender, age, race, body mass index, family history, tobacco use, alcohol consumption, serum beta carotene, serum alpha tocopherol, and serum ferritin. RESULTS: There were 138 controls who had no neoplastic disease, 139 adenoma patients, and 25 cancer patients. Foradenoma,comparing higher quartiles of selenium to the first (lowest selenium), the adjusted odds ratio for the second quartile was 1.7 (95 percent confidence interval, 0.8–3.7), the third quartile was 1.4 (0.7–3.2), and the fourth (highest selenium) quartile was 1.8 (0.9–4). The odds ratios forcancerpatients were 0.8 for the second quartile, 1 for the third quartile, and 1.7 for the fourth quartile. CONCLUSION: No trend could be detected toward a protective effect of higher levels of serum selenium for colonic benign or malignant tumors.

Background. Increased body iron stores have been associated with risk of heart attack in men and risk of cancer and colonic adenoma in both sexes. Because heterozygous carriers of hereditary hemochromatosis (HH) have on the average increased iron stores compared with noncarriers of the HH gene and comprise as much as 15% of the American population, disease risk in HH heterozygotes was investigated. Methods. A community-based cohort was defined, in which the exposure variable was heterozygosity for HH. Heterozygotes were identified by mailing individuals homozygous for HH questionnaires concerning the health histories of their parents (predominantly heterozygotes or exposed). Spouses of the HH homozygotes were asked to complete accompanying questionnaires concerning their parents (unexposed). The frequencies for exposed and unexposed, age-adjusted relative risks (RR), and 95% confidence intervals (CI), of cancer, heart disease, and stroke as causes of death as well as the cumulative incidence of heart attack, diabetes, stroke, hypertension, colonic adenoma, and cancers of the lung, colorectum, breast, cervix, pancreas, stomach, and blood were estimated. Results. Data were available for 1950 HH heterozygotes and 1656 unexposed subjects. Elevated RR were observed in HH heterozygotes in males for diabetes (RR, 1.16 ; 95% CI, 1.01-1.33), colorectal cancer (RR, 1.28 ; CI, 1.07-1.53), and hematologic malignancy (RR, 1.30 ; CI, 1.30-1.63), for colonic adenoma in females (RR, 1.29 ; CI, 1.08-1.53) and males (RR, 1.24 ; CI, 1.05-1.46), and for stomach cancer in females (RR, 1.37 ; CI, 1.04-1.79). Conclusions. Heterozygosity for HH is associated with increased risk for colorectal neoplasia, diabetes, hematologic malignancy, and gastric cancer. No increased risk of heart disease, cancer death, or cancers of the lung, breast, or cervix were demonstrated

BACKGROUND: One of the main concerns in colon carcinoma therapy is local recurrence of the malignancy at the site of resection. Previous studies have shown that morphologically normal-appearing mucosa adjacent to colon carcinoma is different from mucosa distant from carcinoma. Mucosa adjacent to a carcinoma is characterized by crypt lengthening, cell hypertrophy, and change in production of mucopolysaccharides from sulfomucin in normal mucosa to sialomucins in carcinomas and adjacent mucosa. Recently there have been reports suggesting that there is an upward extension of the proliferative compartment in colonic crypts of this adjacent mucosa. METHODS: Immunoblot analysis using antibodies to retinoblastoma, statin, c-Fos, c-Jun, and Cdc-2 proteins was used for our study on the expression of early cell cycle genes in carcinoma and its adjacent mucosa. In all, 15 tissue samples obtained from patients with colon carcinoma were analyzed. Tissue specimens were collected and immediately dissected as tumor, 0 to 1, 1 to 2, 2 to 3, 3 to 4, and 4 to 5 cm from the primary lesion. Dissected pieces were homogenized separately and subjected to immunoblot analysis. RESULTS: We found upregulation of c-Fos, c-Jun, and Cdc-2 expression in carcinoma and adjacent mucosa up to 4 cm from the edge of the carcinoma. The phosphorylated form of retinoblastoma is present in the carcinoma as well as in adjacent mucosa up to 4 cm from the margin of the carcinoma. Furthermore, we observed that the level of statin, a nonproliferation-specific nuclear protein, is very low in the primary lesion and in adjacent mucosa up to 3 cm. CONCLUSIONS: These results indicate that adjacent tissue up to 3 to 4 cm from the carcinoma has elevated levels of expression for cell cycle traverse-associated genes and down-regulation of nonproliferation-specific gene expressions such as statin. This imbalance indicates that within 3 to 4 cm from the edge of the carcinoma, colonic epithelial cells are already abnormal and may be in the hyperproliferative and preneoplastic state, susceptible to further steps leading to eventual malignant transformation.

A 75-year-old woman was initially examined in the emergency department for fever, elevated leukocyte count, and new-onset right lower extremity tingling for 1 day. Physical examination revealed a large pelvic mass. Abdominal computed tomography (CT) revealed a large presacral mass. A biopsy showed that the mass was not malignant. A whole-body white blood cell (WBC)-labeled study was ordered for further evaluation. Both CT and the leukocyte examinations revealed findings consistent with a pelvic mass that extended posteriorly and laterally in both directions. The patient was taken to surgery and a diagnosis of perforated diverticulitis with an abscess located posterior to the rectum and dissecting laterally in the pelvis was confirmed. The patient recovered from surgery and is now symptom free.