bluuebunny/crossref_metadata_2025 huggingface dataset:
CR10 MRI CRITERIA FOR SELECTING PATIENTS FOR PREOPERATIVE RADIOTHERAPY IN RECTAL CANCER
Authors: Bissett I. P. , Shannon D. E. , Bates N.
Published: April 2009

Purpose:   Preoperative radiotherapy (PRT) reduces the risk of local pelvic recurrence (LR) after rectal cancer surgery but is associated with considerable side‐effects. This study aims to identify the LR rate associated with the present MRI based selection criterion for PRT (tumour threatening the fascia propria on MRI) at Auckland City Hospital (ACH), and to assess the likely influence on LR rates of a regimen using a PRT selection criterion based on a 5 mm clearance of the fascia propria.

Methodology:   All patients with rectal cancer treated at ACH from 1997–2005 who had preoperative MRI scans were identified from the National Cancer Registry. Details of demographics, MRI results, treatment and outcome were collated. Long‐term outcomes were obtained from digital records, GPs, patient contact and death‐certificates. All MRIs were re‐reported using the new criterion of 5 mm clearance for the fascia propria.

Results:   There were 126 patients eligible patients, 20 were excluded with lack of MRI or follow‐up. 106 patients (mean age 66.5 years, 67% male) were followed‐up for a minimum 2 years (med 3 years). Using the present MRI based ACH criteria for PRT 29 (27%) patients were irradiated. Using a 5 mm tumour free margin 80 (75%) of patients would have been offered PRT. Overall 7 (6.6%) patients developed LR, 6 of these did not receive PRT, 4 of these fulfilled the new criterion and only 2 of these patients had a resection with curative intent.

Conclusion:   Selective PRT based on threatened fascia propria involvement on MRI lead to low PRT and LR rates. The use of a 5 mm tumour free lateral margin on MRI would result in three times as many patients receiving PRT and is likely to reduce the local recurrence rate by about 2%.
CR12 *SELF‐EXPANDABLE METALLIC STENT VS SURGERY IN MANAGEMENT OF ACUTE MALIGNANT LARGE BOWEL OBSTRUCTION
Authors: Braun W. V. , Abdool I. S. , Lim A. , Frenkiel B. , White S. I.
Published: April 2009

Background:   Management of acute LBO remains challenging. An urgent surgical intervention is often associated with poorer clinical outcome compared to an elective procedure. SEMS as BTS or palliative measure remain controversial and not widely available.

Methods:   From 1995 to 2008, retrospective analysis of the patients presenting with an acute malignant LBO to the Tweed and John Flynn Private Hospitals was performed.

Results:   SEMS were inserted in 31 patients (median age 74 (46–95), 17 females and 14 males, ratio 1.2:1). 12 were elective and therefore excluded. The remaining 19 had emergency SEMS insertion – 12 as BTS and 7 palliative. LOS was 4.5 days (2–21). Tumour was located in the left colon and the rectum (15) and transverse colon (4). 15 patients experienced complete resolution of LBO. 10 patients from the BTS group had subsequently undergone one‐stage curative resection with good outcome. There were 2 deaths and 2 unsuccessful SEMS placements. Urgent operation was performed in 23 patients (median age 74 (52–89), 10 males and 13 females, ratio 1.3:1): 18 Hartmann's procedures, 3 resections with primary anastomosis and 2 defunctioning colostomies. LOS was 17.7 days (2–59). There was 1 death, 1 ongoing pelvic sepsis, 5 significant wound complications, stoma prolapse, AMI, IHD exacerbation, 2 episodes of AF, 3 UTI, pneumonia and 3 cases of prolonged ileus.

Conclusions:   In expert hands SEMS are effective in treatment of LBO. They are associated with an overall better outcome and improved quality of life of patients. Surgery is indicated, where SEMS are unavailable or have failed.
CR13 *EARLY SURVEILLANCE COLONOSCOPY FOR METACHRONOUS COLORECTAL CANCER
Authors: Hollington P. , Tiong L. U.
Published: April 2009

Introduction:   Colorectal cancer is the 3rd most common cause of cancer deaths in Australia. The Australian NHMRC guideline recommends regular surveillance colonoscopy every 3–5 years after curative surgery. Some studies recently reported disturbing rates of metachronous colorectal cancer occurring early after curative treatment of the index tumour. There are concerns that performing surveillance colonoscopy only 3–5 years after curative surgery may miss a significant proportion of metachronous cancers. This study looks at the rate and timing of metachronous cancer in two institutions, and examines factors which may be associated.

Methods:   This is a retrospective audit utilising a database of all patients undergoing surveillance colonoscopy at Flinders Medical Centre and Repatriation General Hospital. Patients were identified using the database, with subsequent case note review. Patients with familial disorders or disease recurrence at anastomotic sites within 12 months were excluded. This audit has been approved by the Ethics and Research Committee of both hospitals.

Results:   Colorectal cancers were identified in 569 patients, of whom 15 (2.6%) had metachronous cancers and were included in our study. There were 10 men and 5 women with average age of 74 years. The median time interval to detection of metachronous cancer was 36 months (range 13–202 months). 8 (53%) patients had metachronous cancer identified at between 13–36 months after diagnosis of the primary tumour.

Conclusion:   Our study showed that a significant proportion (53%) of patients who had metachronous colorectal cancer presented within 13–36 months. Early surveillance colonoscopy may be warranted to detect earlier stage disease relapse.
CR14 *ANAL INTERSPHINCTERIC NERVE BLOCK PRIOR TO RUBBER BAND LIGATION OF HAEMORRHOIDS. IS IT EFFECTIVE? A RANDOMISED CONTROL TRIAL
Authors: Collins S. J. , Von Papen M.
Published: April 2009

Purpose:   Significant pain and discomfort are reported by a proportion of patients undergoing rubber band ligation of haemorrhoids. Several nerve blocks have been trialled with varied results. The aim of this study was to determine whether an anal intersphincteric nerve block may reduce post‐operative pain and analgesic requirements in these patients.

Methodology:   One hundred sequential patients undergoing rubber band ligation of haemorrhoids were randomised to either an anal intersphincteric nerve block using 0.5% Marcaine with adrenaline or to the control group. The procedures were performed by a single surgeon using the KilRoid (TM) rubber band ligator (Astratech – Sweden). Patients were assessed for pain and analgesic use in the immediate post operative period and at 24 hours. Both the patient and data collector were blinded to whether a nerve block had been administered.

Results:   There was no statistically significant difference between the two groups in median post operative pain (3.0 vs. 2.0 p > 0.0.29), median post operative analgesic use (1.6 vs. 3.3 p = 0.62), median pain score at 24 hour (4.14 vs. 4.22 p = 0.9) and median analgesic use at 24 hours (1.0 vs. 1.0 p = 0.13).

Conclusions:   There is no benefit from performing an intersphincteric nerve block in patients undergoing rubber band ligation of haemorrhoids.
CR15 *IS SACRAL NERVE STIMULATION A VALID TREATMENT FOR FAECAL INCONTINENCE?
Authors: Lutton N. J. , Patton V. , Lubowski D. Z.
Published: April 2009

Purpose:   Sacral nerve stimulation (SNS) is a promising new modality to treat faecal incontinence. This study was designed to examine patient satisfaction with the procedure and relate this to changes in quality of life (QoL) and incontinence scores.

Methodology:   Twenty‐eight patients underwent insertion of a permanent stimulator after temporary stimulation had achieved a good result. Faecal incontinence QoL data, incontinence scores (scale 0–24) and baseline anorectal physiology measurements were recorded prospectively in a database, together with a postoperative survey and repeat physiological investigations.

Results:   Twenty‐four patients (86%) completed the survey. The median age of patients at the time of SNS insertion was 62 yrs (range 47–83) and median follow‐up was 10 months (2–50 m). The mean St Mark's incontinence scores were 16.9 pre‐operatively and 10.6 post‐operatively (p < 0.001). Faecal incontinence quality of life (FIQL) measurements showed statistically significant improvements across all domains (lifestyle p = 0.02, coping p < 0.01, depression p = 0.01 and embarrassment p < 0.01). Mean patient satisfaction was 6.8 (visual analogue scale of 0–10). This score showed statistically significant correlations with both incontinence scores and three out of four FIQL domains. No correlation was seen with duration of treatment and patient satisfaction.

Conclusion:   SNS is a valid procedure for faecal incontinence as demonstrated by significant improvements in incontinence scores, FIQL measurements and these improvements are closely correlated to patient satisfaction with the procedure.
CR02 AUSTRALASIAN LAPAROSCOPIC COLON CANCER STUDY (ALCCAS): LOWER POSTOPERATIVE COMPLICATION RATES BENEFIT ELDERLY PATIENTS
Authors: Allardyce R. A. , Bagshaw P. F. , Frizelle F. A. , Hewett P. J. , C. M. F.  , Rieger N. A.
Published: April 2009

Purpose:   We report the age‐related peri‐operative morbidity findings of the Australia and New Zealand prospective randomised controlled trial (RCT) comparing laparoscopic (LCR) and open (OCR) surgical treatments of right‐ and left‐sided, potentially curable, colon cancer.

Methods:   Between January 1998 and April 2005, 601 eligible patients were recruited by 33 surgeons from 31 Australian and New Zealand centres. Complications were analyzed by an independent reviewer. Their severity was classified as; mild, moderate or severe and their relatedness to surgery as; not, probably not, possibly or definitely.

Results:   294 patients had LCR and 298 had OCR. 266 patients were < 70 and 326 ≥70 years (mean = 70.3 ± 11 years). There were 43 (14.6%) conversions from LCR to OCR, of which 35 (81%) had a complication. The numbers of surgical (p = 0.003) and medical (p = 0.043) complications were reduced in completed LCR operations when compared with OCR. These differences were attributable to significantly lower numbers of complications in patients ≥70 years (surgical, p = 0.002; medical, p = 0.043). Likewise, the numbers of individuals experiencing any complication favoured LCR treatment (p = 0.001) and specifically those ≥70 years (p = 0.004).

Conclusion:   Treatment choices for colon cancer depend upon survival and tumour recurrence, short‐term outcomes, costs and quality of life measures. If LCR is proven safe and affordable, our results suggest that patients ≥70 years with potentially curable colon cancer be rigorously investigated preoperatively to avoid conversions and then considered for LCR.
CR20P ANASTOMOTIC LEAKAGE AFTER RESECTION OF COLORECTAL CANCER GENERATES PRODIGIOUS USE OF HOSPITAL RESOURCES
Authors: Chapuis P. H. , Sinclair G. , Dent O. F. , Frye J. N. , Bokey L. E.
Published: April 2009

Objective:   The aim of this study was to determine the demand for hospital resources generated by anastomotic leakage, including surgical, medical, imaging, pathology, and other allied health consultations or services and length of postoperative hospital stay.

Patients and Methods:   Data were obtained from a comprehensive, prospective hospital registry of all resections for colorectal cancer from January 1995 to December 2004 and from retrospective review of patients’ notes.

Results:   Forty‐one patients with a leak spent 92 days in intensive care, required 129 days of total parenteral nutrition, 69 days of enteric feeding and 41 days on ventilation and had a median postoperative hospital stay of 28 days (range 11–104). These patients required 24 re‐operations and 2,273 separate medical consultations or allied services.

Conclusion:   Anastomotic leakage generates a very considerable demand for hospital resources and diverts these resources from the hospital population at large.
CR21P COMPLEX ANAL FISTULAS: PLUG OR FLAP?
Authors: Muhlmann M. D. , Hayes J. , Merrie A. , Parry B. , Bissett I.
Published: April 2009

Purpose:   Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair.

Methodology:   A retrospective review of all complex anal fistulas treated, by either a RMAF or a FP, at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of MRI.

Results:   Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. 21 patients (30%) had had at least 1 previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch‐vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. 48 RMAF's (69% of total) were performed with 16 successful repairs (33%). 22 FP's (31% of total) were performed with 7 successful repairs (32%, p = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months vs. FP 4.1 months, p = 0.62). MRI was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%.

Conclusion:   The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.
CR25P FAILURE TO ATTEND FOLLOW UP APPOINTMENTS IN PATIENTS WITH COLORECTAL CANCER – HOW COMMONLY DOES IT OCCUR AND WHY?
Authors: Shimokawa K. , Shedda S. , Pem A. , Jones I. , Gibbs P.
Published: April 2009

Introduction:   Follow up after curative resection for colorectal cancer has been demonstrated to improve survival and failure to attend (FTA) may compromise patient outcomes. The incidences of FTA and the causes have not been documented.

Methods:   Patients were identified from a prospective clinical database and a hospital based appointment system. FTA follow up was defined as non‐attendance of at least one appointment, within 5 years post operatively. A phone interview was used to evaluate the cause. Patients from a non‐English speaking background (NESB) were contacted with interpreters.

Results:   From January 2003 to May 2008 622 patients with stage I‐III cancer were identified, including 202 from a NESB. 125 non‐attendees were identified. 61 patients (70%) were contacted from 87 surviving patients. 26 could not be located and 38 patients were deceased. Of the 61 patients studied, 32(52%) were male. The mean age was 68 years (range 33, 102). 14 patients (23%) were from a NESB. Each non‐attendant averaged 16 appointments, and 1.7 failed attendances. A median of > 13 months elapsed from diagnosis to 1st missed appointment. The main reasons for non attendance were: unaware of the appointment (n = 21), inconvenience due to time or travel (n = 14), poor health (n = 10), long waiting times (n = 8), forgetting (n = 6) and other (n = 2). Age, sex and number of booked appointments were not associated with non‐attendance.

Conclusion:   Failure to attend follow‐up appointments is common. Overall, access to follow up was prevented by structural factors more than disease/patient factors. A common reason for non‐attendance was that patients were unaware of the appointment. Opportunities for significantly improving attendance include a reminder system.
CR26P LAPAROSCOPIC HYBRID RECTAL RESECTION FOR RECTAL CANCER
Authors: Shedda S. M. , Hayes I. , Jones I. T. , Hastie I. , Gibbs P.
Published: April 2009

Introduction:   Laparoscopic anterior resection for rectal cancer remains controversial due to the possibility of a positive circumferential margin with the laparoscopic approach. The “hybrid procedure” has been performed with laparoscopic colonic mobilization but rectal dissection is through a Pfannenstiel incision.

Methods:   Data from a prospective single institution rectal cancer database was used to compare hybrid, converted and open anterior resections for mid and low rectal cancer from February 2003 to August 2008.

Results:   There were 253 patients found. There were 66 (26%) hybrid (H), 5 (2%) converted (C) and 182 (72%) open (O) cases. The median follow up all 3 groups was similar. 30 (h), 28 (C), 34 (O) months. The median length of stay (days) was shorter in the (H) group. [6.5 (H), 10 (C), 9 (O), p = 0.001. There was a trend to a higher ASA score, age, median BMI, more wound infections and higher stage in the (O) group. The circumferential margin was involved in 6 (O) group compared with 0 in H) or (C) group (p = 0.5). There were no significant differences in local recurrences [1.1% (O) vs. 1.5% (H&C)] or T stage. There was no difference in neoadjuvant radiation, (48 (26%) (O), 20 (30%) (H), 1 (20%), p = 0.9. The median lymph node count was 11 in each group. The 2 year overall survival was the same both groups, 90% (H), 89% (O) 100% (C) (p = 0.65) as was the progression free survival 76% (H), 64%(O), 80% (C), (p = 0.32).

Conclusion:   The hybrid procedure results in improved short term outcomes for patients with rectal cancer compared to open cases. The hybrid approach did not compromise circumferential margins or lymph node yield, and has no effect in short term progression free or overall survival.
CR27P LAPAROSCOPIC TOTAL COLECTOMY FOR SLOW TRANSIT CONSTIPATION
Authors: Chow C. F. , Brockman S. , Stevenson A. R. , Lumley J. , Stitz R.
Published: April 2009

Purpose:   Slow transit constipation (STC) is a debilitating condition mainly affecting young women. Total colectomy (TC) is an option for patients with severe symptoms who are unresponsive to conservative measures. Open TC has been the procedure of choice but is associated with long term SBO and ongoing symptoms. It is difficult to determine if these ongoing symptoms are related to gut dysmotility or to post operative adhesions. Laparoscopic TC appears equivalent open TC with the advantage of being able to perform a diagnostic laparoscopy at a later stage to divide or exclude adhesions as a cause of chronic obstructive symptoms or pain.

Methods:   All consecutive patients undergoing a laparoscopic TC ± rectopexy for STC from 1991–2007 were reviewed.

Results:   84 patients (81 female, 3 male) were included. Average operating time was 188 min, average LOS 8 days. Conversion rate was 1.2%. There were no post op mortalities. Anastomotic leaks occurred in 2.4%, pelvic collections in 2.4%, intra‐abdominal bleeds in 4.7% and 3.5% developed wound infections. Bowel frequency was significantly improved however, 31% had at least 1 episode of obstructive symptoms. Ongoing pain was experienced by 38%. 57% underwent a further procedure a majority of which was a laparoscopy ± division of adhesions.

Conclusion:   Lap TC is a feasible and acceptable option for patients with STC with reasonable operating times, low conversion rates and acceptable mortality and morbidity. Bowel frequency is significantly improved however long term chronic pain and SBO are common. Lap TC allows for a minimally invasive laparoscopy to be performed to divide or exclude adhesions as a cause for obstructive symptoms or ongoing pain.
CR28P LIVER FUNCTION TESTS AS A BIOMARKER FOR COLORECTAL ANASTOMOTIC LEAKS
Authors: Cao C. Q. , Smith S. , Draganic B.
Published: April 2009

Purpose:   Anastomotic leak (AL) from colorectal surgery is a common and potentially fatal complication that is currently diagnosed clinically with the aid of imaging studies. It has been hypothesized that portal sepsis occurs earlier than clinical signs of peritonism. The present study analysed liver function tests (LFTs) and white cell count (WCC) in patients with AL from colorectal procedures involving primary anastomosis, with the aim of identifying serum parameters that could provide an early indication of AL to allow timely surgical intervention.

Materials and Methods:   Between November 2003 and December 2008, 1243 consecutive colorectal procedures involving primary anastomosis from our institution were retrospectively screened for AL. LFTs and WCC of the identified patients were extracted from a central database for analysis.

Results:   From our database, we found thirty‐four patients who required operative intervention and had confirmed AL according to their operation reports. Elevated levels of GGT above 115 and ALP above 55 were found in 71% and 61% of patients, respectively, prior to clinical anastomotic leakage. WCC appeared to remain on the upper border of the normal range in the majority of patients.

Conclusion:   Elevated median levels of GGT and ALP in this group of patients after the initial colorectal procedure is suggestive that LFTs may be a useful biomarker for anastomotic leaks. Further research in prospective trials should be performed to evaluate its usefulness.
CR03 *ILEOCOLIC RESECTIONS FOR CROHN'S DISEASE: IMPACT OF MEDICAL THERAPY
Authors: Bernardi M.‐P. , Heriot A. G. , Sutherland A. , Woods R. , Keck J. , Johnston M.
Published: April 2009

Purpose:   Ileocolic resection is the commonest surgical resection performed for Crohn's disease. The aim of the study was to review outcomes of primary ileocolic resections for Crohn's disease with particular emphasis on complications, recurrence and impact of prophylactic medication.

Methodology:   Retrospective chart review was undertaken on all patients undergoing ileocolic resection for Crohn's disease between July 1998 and June 2008 at a tertiary centre. Data collected included patient demographics, pre‐operative medication, technical aspects of surgery, complications, prophylactic medical therapy and recurrence of disease.

Results:   There were 64 patients (28 male, 36 female), mean age 30.2 years (SD 10.6). Surgery was elective in 49 patients (76.6 %) and urgent in 15 (23.4%). Laparoscopic surgery was undertaken in 31 (48.4%) with 3 converted to open (9.7 %). High anterior resection was performed in addition in 9.4% for contiguous disease. Post‐operative complication rate was 17.2% (anastomotic leak 6.3%; intra‐abdominal abscess 4.7%; pulmonary embolus 3.1%; other 3.1%). Endoscopic disease recurrence occurred in 27 (42.2%) of patients with mean time to recurrence 1.8 years (SD 1.3). Surgical intervention for recurrent disease was required in 5 (7.8%) and 40% of these developed further recurrence on imaging after repeat surgery. Prophylactic medications following primary resection did not reduce risk of recurrence (recurrence [prophylaxis/no prophylaxis], 21 vs. 6; no recurrence, 26 vs. 11; p = NS).

Conclusion:   Almost half of patients who have an ileocolic resection for Crohn's disease will develop recurrence though less than 10% require further surgery. Prophylactic medical therapy does not reduce recurrence.
CR30P METACHRONOUS COLORECTAL CANCER
Authors: Carmichael R. W. , Siu S. , Ho Y.‐H.
Published: April 2009

Purpose:   The purpose of this article is to review the current knowledge relating to risk factors, tumorigenesis and survival of patients with metachronous colorectal cancer to address potential advances in surveillance and management of patients with colorectal cancer.

Methodology:   The Cochrane Library, PubMed, EMBASE and Ovid databases were searched from 1966 to December 2008 for both published reviews and published articles on metachronous colorectal cancer regarding incidence, carcinoma sequence, clinical characteristics, risk factors, detection, treatment, surveillance and survival. Further articles were obtained by a manual review of the reference lists of all retrieved articles. All publications relevant to this study were included.

Results:   Factors likely to increase the risk of developing metachronous colorectal cancer include; age, personal and family history of multiple malignancies, synchronous polyps, hereditary non‐polyposis colorectal cancer and microsatellite instability.

Conclusion:   Pre‐operative colonoscopic polyp status and biopsy analysis regarding microsatellite instability are essential in identifying patients at risk of metachronous colorectal cancer. A rapid adenoma‐carcinoma sequence less than the accepted 2 to 5 years would warrant stringent colonoscopic surveillance. Thus, frequent colonoscopic surveillance is recommended, within the first 5 years post‐operatively, for the detection of metachronous colorectal cancer.
CR32P PREDICTORS OF DAY STAY AFTER COLONIC SURGERY IN A STRUCTURED MULTI‐MODAL CARE PROGRAM
Authors: Kahokehr A. A. , Sammour T. , Sahakian V. , Zargar‐Shoshtari K. , Hill A. G.
Published: April 2009

Background:   Enhanced Recovery After Surgery (ERAS) programs have gained popularity in colonic surgery. Hospital stay has been reduced dramatically as a result, but remains varied in the published literature. We were interested in investigating the factors that influence hospital stay in an ERAS setting.

Methods:   Between October 2005 and November 2008 prospective data were collected on consecutive patients undergoing elective colonic resection, without a stoma, at a single site. Patients were managed within an ERAS program. Patients unable to communicate in English, with dementia or ASA >4 were excluded. Variables were tested using the Mann‐Whitney U and Spearman's two tailed correlation table for continuous data. Cox regression analysis was used for modelling.

Results:   102 patients were included. There were 57 right sided, 43 left sided and 2 total colectomies. Mean age was 66 years (95% CI, 40–88). Median day stay was 4 days (range 3–46). Indications for surgery were: malignancy (80%), diverticular disease (13%) and other (7%). Age, operation site, ASA, indication for surgery and BMI were not significant predictors of hospital stay. Factors with the strongest correlation for reduced day stay were Cr‐Possum score (p = 0.006), female sex (p = 0.013), laparoscopic (n = 6) and transverse (n = 32) incisions (p < 0.001), and the operating surgeon (p < 0.001). Using Cox regression modeling, surgeon and patient gender could be eliminated as independent predictors of day stay. The other two factors added significant strength to the model.

Conclusion:   Choice of incision and Cr‐POSSUM score are independent predictors of day stay in the ERAS setting.
CR34P STOMAS ARE STILL USED IN COLORECTAL TRAUMA
Authors: Nguyen T. C. , Shedda S. , Jones I. T. , Judson R. , Hayes I. , Hastie I.
Published: April 2009

Purpose:   We aimed to assess the management of colorectal and anal injuries in trauma patients at a single major metropolitan trauma hospital in Australia.

Methods:   A prospectively collected database at a major metropolitan trauma centre was assessed to retrieve consecutive patients who had colorectal and anal injuries over a 12 year period.

Results:   185 patients were identified with colorectal or anal injuries from February 1996 to June 2008. The mechanism of injury was blunt in 145 (78%) with 134 (72%) related to motor vehicle trauma. The remaining 40 (22%) were due to penetrating injuries. There were 165 (89%) colonic injuries, 5 (3%) rectal injuries and 15 (8%) perineal injuries. 106 (57%) patients had multiple site of colonic or multiple organ injuries. 46 (25%) patients had full thickness tear of the colon with only 2 having full transection of the colon. The rest had contusions, serosal tears or mesocolon injury. The median injury severity score was 27 (range 4–75). 134 (72%) patients had surgical intervention including 61 repairs, 30 resections and 12 stomas, 3 of which occurred in major perineal injuries. The in hospital mortality rate was 5.4% with major or minor morbidity occurring in 52%. This included 3 anastomotic leaks and 2 missed injuries requiring a second laparotomy. 12 (6%) patients were subsequently readmitted after the initial management.

Conclusion:   Colorectal injuries are usually due to road trauma with the majority occurring in the colon and over half these patients have multiple injuries. The complication rate is significant but relatively few of these are related to anastomotic leak when primary anastomosis is undertaken. Stomas however continue to be used.
CR36P TREATMENT OF ANAL FISTULA WITH THE COLLAGEN FISTULA PLUG
Authors: Hore T. , Hammodat H.
Published: April 2009

Purpose:   We investigated the use of ‘Surgisis’ anorectal fistula plug in the treatment of anorectal fistula. Success rates quoted have been variable. There is no known data regarding when to reattempt the ‘Surgisis’ plug if failure occurs. We assessed our success rate and looked at any pattern for reinsertion of the ‘Surgisis’ anorectal plug.

Methodology:   We retrospectively collected patient/fistula characteristics, procedure details, and follow‐up information for all patients treated with the anal fistula plug at our institution over the past 5 years. The outcome was considered successful if the external and internal opening were closed and if the patient had no drainage at the last follow‐up.

Results:   Of 16 patients, 21 fistulae were treated with the ‘Surgisis’ anorectal fistula plug. 28.5% had complete healing after the first attempt at insertion of the ‘Surgisis’ plug, while 28.5% required a reinsertion of the ‘Surgisis’ plug for complete healing to occur. 43% failed to heal with the insertion of the ‘Surgisis’ plug or were awaiting follow‐up. The period of time between insertion of seton, subsequent failure and insertion of ‘Surgisis’ plug was extremely variable. Median time taken was 220 (41–553) days. Following this the median time taken for reinsertion was 303 (151–495) days.

Conclusion:   Collectively our success rate for ‘Surgisis’ plug insertion is 57% however only 28.5% after first insertion. There is no clear relationship between the time period and the success of reinsertion of the ‘Surgisis’ plug. More data is required to give clear guidelines for timing of ‘Surgisis’ plug reinsertion.
CR05 *POSTERIOR TIBIAL NERVE STIMULATION: A TREATMENT FOR FAECAL INCONTINENCE?
Authors: Yeung J. M. , Findlay J. , Maxwell‐Armstrong C.
Published: April 2009

Purpose:   Faecal incontinence (FI) is a prevalent and important multifactorial condition. Neuromodulation via implanted sacral nerve stimulators is efficacious, but as with other invasive treatment modalities is expensive and associated with significant complications. Peripheral neuromodulation of sacral nerve roots via posterior tibial nerve stimulation (PTNS) is effective in urinary incontinence, but there is minimal evidence for its use in FI. This study aimed to assess the efficacy of PTNS in FI.

Methodology:   12 patients with FI of various causes (8 idiopathic, 3 obstetric, 1 previous anorectal surgery) underwent PTNS at a UK hospital. All were investigated with colonic imaging, anorectal physiological studies and endoanal ultrasound. Prior treatments comprised physiotherapy (12), sphincter repairs (3 biofeedback (3) and implants (1). PTNS was performed for 30 minutes, weekly for 12 weeks. Outcome measures were episodes of incontinence, the Hospital Anxiety and Depression Scale and Rockwood Faecal Incontinence Quality of Life score.

Results:   Mean monthly episodes of incontinence of wind, liquid and solid before treatment were 18.77, 21.77 and 22.15 respectively. After 12 weeks’ treatment this had reduced to 0.92, 0.83 and 0.83 respectively (p < 0.05). Sphincter integrity, physiology and aetiology were not shown to affect efficacy. No patient's incontinence worsened. Non‐significant improvements in Anxiety and Depression and quality of life scores were also seen.

Conclusions:   This is the first UK study to demonstrate PTNS as a potentially efficacious and minimally invasive alternative treatment modality for faecal incontinence. These early results are encouraging, but we await medium and long term follow up.
CR06 *LAPAROSCOPIC ANTERIOR RECTOPEXY FOR EXTERNAL PROLAPSE IS SAFE IN THE ELDERLY AND MAKES PERINEAL PROCEDURES ALMOST OBSOLETE
Authors: Akbar A. , Wijffels N. , Cunningham C. , Dixon A. , Lindsey I.
Published: April 2009

Purpose:   Perineal procedures, despite high recurrence (pooled published series 18%) and poor function, are gold standard for external rectal prolapse (ERP) in the elderly for safety. Abdominal rectopexy has lower recurrence (<5%), but performed posteriorly induces constipation in 50% and open has higher morbidity. Laparoscopic anterior rectopexy (LAR) overcomes these limitations, improving constipation with low recurrence. We aimed to assess efficacy and safety of LAR for ERP in the elderly.

Methodology:   Data on LAR for ERP >80 from 2 tertiary colorectal pelvic floor services in Oxford and Bristol were collected prospectively and analysed. End‐points were mortality, morbidity, length of stay (LOS). A subgroup was analysed for change in bowel function (Wexner constipation score and Faecal Incontinence Severity Index [FISI]). A comparison was made with a cohort of patients <80 years.

Results:   81 patients (1 Delorme's in this period) 80 years or more (28% of total) were compared with 149 patients under 80 (98% vs. 86% female, age median 84 vs. 60 years, range 80–97 vs. 16–79 years). 30‐day mortality (0% vs. 0%), morbidity (11% vs. 3%+), LOS (2 vs. 2 days) and recurrence (2% vs. 0%) was acceptably low and similar in both age cohorts. Functional results were excellent, both cohorts showing improvement in constipation (median Wexner pre‐op 10 to post‐op 3 vs. 10 to 4, new‐onset constipation negligible) and incontinence (median FISI 31 to 0 vs. 34 to 8, resp.).

Conclusions:   LAR is safe and can be offered to all fit elderly ERP patients. Perineal procedures should be restricted to the very frail.
CR07 *IMMUNOHISTOCHEMISTRY FOR LOSS OF EXPRESSION OF MISMATCH REPAIR GENE PROTEINS IN YOUNG PATIENTS WITH COLORECTAL CANCER: THE AUCKLAND EXPERIENCE
Authors: Wright D. M. , Parry S. , Arnold J. , Bissett I. , Hulme‐Moir M. , Parry B.
Published: April 2009

Recently, in Australasia, a plea to screen all young patients with colorectal cancer (CRC) for Lynch syndrome has been advanced1.

Since 2001 the three public hospitals in Auckland have had the policy of undertaking immunohistochemical (IHC) testing on the tumours of patients aged 50 years and under to detect loss of expression (LOE) of protein products for the mismatch repair (MMR) genes MLH1, MSH2, MSH6 and PMS2.

Purpose:   To determine (1) the completeness of patient capture, (2) the incidence of LOE by IHC of the 4 gene proteins, and (3) to correlate IHC results with those of subsequent genetic testing for the corresponding germline mutations.

Methodology:   Retrospective review of the prospectively gathered clinical, pathological, and genetic records of all patients diagnosed with CRC aged 50 years and below between January 2001 and December 2007.

Results:   244 patients aged 50 years or below with CRC were diagnosed in this period. 212 (86.9%) patients’ tumours underwent IHC, 147 of which had all 4 gene products studied. 30 (14.2%) tumours had LOE for one or more MMR proteins. 25/30 patients were offered genetic testing of whom 3 declined. So far 8 out of 16 patients tested have a confirmed germline mutation. Only 3/8 patients report a family history of CRC.

Conclusion:   Tumour IHC reveals LOE for one of the four MMR gene proteins in approximately 14% of young patients developing CRC and in half subsequent genetic testing will identify Lynch syndrome. A policy of mandatory testing is confirmed but audit of performance and appropriate referral is required.
CR08 *PARASTOMAL HERNIA PREVENTION USING A NOVEL COLLAGEN IMPLANT: A RANDOMISED CONTROLLED PHASE 1 STUDY
Authors: Frye J. N. , Hammond T. M. , Prosser K. , Huang A. , Williams N. S.
Published: April 2009

Background:   Parastomal hernias can be prevented or repaired using synthetic mesh; however, reported complications include infection, fibrosis and potential bowel erosion. The study aim was to assess the safety, feasibility and potential efficacy of using a prophylactic collagen implant.

Methods:   Twenty patients undergoing defunctioning stomas were randomised to a conventional procedure or reinforcement with the implant. Follow‐up included regular symptom questionnaires, clinical examination, stoma site ultrasound, and serum inflammatory markers.

Results:   Ten patients (four males; mean BMI 26.3) had a conventional stoma, and ten (three males; mean BMI 26.3) received the implant. At a median of 6.5 months follow‐up, a parastomal hernia was clinically evident in three of ten patients without the implant, and in none of ten patients with the implant. There were no clinical complications, ultrasound evidence of chronic seromas or serological evidence of a systemic inflammatory response.

Conclusions:   Xenogeneic collagen has been demonstrated to aid soft tissue reinforcement. In this study, in contrast to published data relating to the use of conventional synthetic mesh, there were no complications related to infection or the implant's proximity to the bowel. This trial demonstrates that the implant is safe, feasible to use and has the potential to prevent parastomal herniation.
ES13 *SURGEON PERFORMED, ULTRASOUND GUIDED, FINE NEEDLE ASPIRATION BIOPSY OF THYROID: A SAFE, CONVENIENT AND EFFECTIVE DIAGNOSTIC TECHNIQUE
Authors: Law M. T. , Bennett I. C.
Published: April 2009

Purpose:   Office‐based ultrasound is becoming increasingly popular and is a great adjunct to conventional diagnostic techniques such as thyroid FNAB. We aim to evaluate the performance of surgeon performed ultrasound (US) guided FNAB of thyroid, focusing on its accuracy, and safety.

Method:   Performance of US guided FNAB performed in a single surgeon practice between 2006 and 2008 was retrospectively reviewed, with emphasis on non‐diagnostic and complication rates. Factors affecting FNAB outcome were tested using Chi‐square test and significance defined as p < 0.05

Results:   128 FNABs were performed on 100 patients. Mean lesion size was 22 mm, majority were solid on US. US FNAB had sensitivity of 85%, accuracy 75%. Non‐diagnostic rate was only 5.5% with no complications. Malignant or atypical findings accounted for 12%. 22% of cases proceeded to thyroidectomy, 46% of which yielded malignancy. Lesions which were solid and <2 cm in size were associated with significantly higher non‐diagnostic rate (p = 0.04). Most patients had their consultations and US FNABs in the same sitting.

Conclusion:   Performance of surgeon performed thyroid US guided FNAB compares favourably to radiologist performed series. It is superior to FNABs by palpation and is associated with low complication. Consideration should be given to using on‐site cytology assessment for smaller solid lesions to reduce non‐diagnostic rate. US FNAB is easily learned through structured training, imparts great convenience to both surgeons and patients and is cost effective.
ES14 *CAN CYTOLOGY EXCLUDE THYROGLOSSAL DUCT CYST PAPILLARY CARCINOMA?
Authors: Eteuati J. , Serpell J. W.
Published: April 2009

Background:   Thyroglossal duct cysts (TDC) are the commonest midline neck mass. They occur in approximately 7% of the population. Thyroglossal duct carcinoma is uncommon but is reported in 1% of all thyroglossal cysts. Sistrunk's procedure is the accepted treatment for TDC.

Aims:   The aims of this study were: to determine the incidence of Papillary Thyroid Cancer in TDC; to compare cytology from the cyst and final histopathology; and to assess the adequacy of Sistrunk's procedure.

Method:   A retrospective analysis of prospectively collected data of all TDC operations performed by the unit within a 15 year period, 1993–2008, was undertaken.

Results:   There were 39 patients; 14 males and 25 females, of median age 40 (range 17–79) years. The main presenting symptom was a neck lump, ranging from 1 week to 17 years and mainly in the midline (33/39). The imaging modality of choice was ultrasound of the neck which correctly identified a cystic structure likely to be a TDC in the neck in 31/33 cases (94%). Fine needle aspirate cytology (FNAC) in 24 patients predicted a benign TDC with a sensitivity of 95.6% and a specificity of 100%. Papillary Thyroid Cancer occurred in four TDC, an incidence of 10%. All patients had a Sistrunk's procedure, from which there were no recurrences. Two of the Papillary Thyroid Cancer patients underwent total thyroidectomy. There were six minor complications, a rate of 15%.

Conclusion:   The incidence of Papillary Thyroid Cancer in TDC was 10% in this series. The remaining lesions were benign and FNAC correctly predicted this with a sensitivity of 95.6%. Sistrunk's procedure is adequate treatment with minimal complications and no recurrences.
ES15 *RECURRENT LARYNGEAL NERVE PARALYSIS AND DELAYED PRESENTATION OF THYROID CANCER
Authors: Suliburk J. W. , Shaw E. , Sidhu S. B. , Sywak M. S. , Delbribridge L. W.
Published: April 2009

Background:   Recurrent laryngeal nerve paralysis (RLNP) is well recognized as a presenting symptom of thyroid malignancy, however RLNP is more commonly due to other aetiologies such as post‐viral paralysis. The onset of a hoarse voice in a patient with a presumed benign multinodular goiter can thus present diagnostic difficulties and may lead to significant delays in the diagnosis of thyroid cancer.

Methods:   Data were obtained from the University of Sydney Endocrine Surgical Unit database. The study group comprised all patients presenting with a pre‐operative diagnosis of RLNP prior to thyroid surgery in the 10 year period 1999 to 2008.

Results:   During the study period there were 44 thyroidectomies performed in cases of preoperative RNLP. 16 of these patients (36%) had cancer on final pathology with 14 having well differentiated thyroid cancer. In 3 (18%) of these patients the diagnosis was markedly delayed due to associated multinodular goiter. Mean delay from onset of RLNP to diagnosis of cancer in these 3 patients was 7 years (range 3 to 9 years). Each of these patients had normal neck CT, thyroid nodules of < 8 mm on initial imaging and initial benign FNA. In all 3 patients intra‐operative findings noted tumour posteriorly at the Tubercle of Zuckerkandl and histopathology confirmed invasion of the nerve by papillary carcinoma.

Conclusion:   RLNP may be a sign of occult malignancy in the Tubercle of Zuckerkandl. Small tumour size and posterior location on the gland make reliable imaging and FNA difficult. Patients in whom malignancy is initially excluded should have close follow up and reassessment as there is a significant false negative rate in this patient cohort.
ES16 *GENOTYPE PHENOTYPE CORRELATION IN AN AUSTRALASIAN MEDULLARY THYROID CANCER
Authors: Sywak M. , Abraham D. T. , Messina M. , Sidhu S. B. , Robinson B. G. , Delbridge L.
Published: April 2009

Purpose:   The aim of this study is to review the genotype‐ phenotype correlation in patients with medullary thyroid cancer in an Australian cohort.

Methodology:   Patients were identified from a prospectively maintained surgical database. Clinical features of tumour size, pre‐operative calcitonin, rate of lymph node metastases, disease free survival, tumour recurrence, RET mutations, were statistically assessed using the Stata software package.

Results:   Eighty patients were identified between 1967 and 2006. Fifty‐three had sporadic MTC (sMTC) and 27 had familial MTC (fMTC). Significant difference p < 0.05 to p < 0.001 between the two groups was found in the following features: tumour size, pre‐operative serum calcitonin, rate of lymph node metastases where sMTC was consistently higher when compared to fMTC. In addition, disease‐free survival were significantly different between the two groups (81% in fMTC vs. 72% in sMTC, p = 0.041). The review of genetic mutations in RET revealed that the 5 year disease free survival for patients with codon 804 mutations was greater than for those with codon 618, 620 and 634 mutations, considered low and intermediate risk groups respectively. Since the introduction of genetic testing, patients with fMTC were detected at an earlier stage with smaller tumour size (13.0 mm vs. 26.0 mm, p = 0.0038), less lymph node metastasis (33% vs. 47%) and better 5 year disease free survival (81% vs. 72%  years).

Conclusion:   Patients with familial form of MTC had better outcome compared to the sporadic counterpart. The type of RET gene mutation influenced the outcome of patients with fMTC. Work on an additional genetic marker that may assist in further disease prognosis and better risk stratification is in progress.
ES20P ECTOPIC MEDIASTINAL PARATHYROID ADENOMA: IS 99MTC SESTAMIBI SCINTIGRAPHY REALLY USEFUL?
Authors: Imisairi A. H. , Hasmah W. W. , Zulkarnain H. , Ziyadi G.
Published: April 2009

Introduction:   Ectopic mediastinal parathyroid tumours that are inaccessible by routine cervical neck exploration account about 1–3% of all parathyroid tumours. 99mTc Sestamibi scintigraphy is said to be one of the good tools for preoperative localization of these glands.

Case Report:   We described the case of a 48 year old lady who presented with generalized malaise and backache for one year duration. Investigations confirmed hypercalcaemia and hypophosphataemia with a total calcium and phosphate level of 3.09 mmol/L and 0.6 mmol/L respectively. Her parathyroid hormone (PTH) level was raised at 18.4 pmol/L. A cervical sonography showed a normal thyroid gland with no suspicious parathyroid glands seen. CT scan of the neck and thorax detected a right anterior mediastinal mass in the thymic region. Finally, 99mTc Sestamibi scanning confirmed an abnormal focal uptake and retention of tracer seen at the right side of the mediastinum suggestive of ectopic parathyroid adenoma. Cervical exploration identified three normal‐looking parathyroid glands in their positions except for absence of the right inferior gland. She subsequently had surgical resection of the mediastinal mass by means of a cervical trans‐manubrial approach. A 4 × 3 cm parathyroid adenoma embedded in the right thymus glandular tissue removed which was confirmed histopathologically. Postoperatively was uneventful. The PTH and calcium levels decreased promptly to normal range.

Conclusion:   Ectopic mediastinal parathyroid adenoma is very rare and usually difficult to diagnose. The use of 99mTc Sestamibi scintigraphy especially in combination with CT scan of the neck and chest will be very helpful to give an accurate preoperative localization.
ES21P LEFT LAPAROSCOPIC ADRENALECTOMY FOR A RARE CAVERNOUS HAEMANGIOMA
Authors: Richter K. K. , Pfeifer M. , Dempster A. , Losco G. , Elliot T.
Published: April 2009

Purpose:   The adrenal gland is an extremely rare location for a cavernous haemangioma, and so far only 53 cases have been reported in the literature. Here, we present a rare case of a laparoscopically resected left adrenal haemangioma. Indication for resection of adrenal incidentalomas, laparoscopic technique, and unexpected histologies are discussed with review of the current literature.

Methodology:   Incidentally a 5 × 4 cm adrenal tumour was diagnosed in a 30 year old female patient. Preoperative imaging was performed and hormonactive tumours were ruled out. Laparoscopic left adrenalectomy was carried out using a transabdominal lateral flank approach. After mobilization of the spleen and rotation of the tail of the pancreas medially the adrenal vein was endoscopically clipped. Mobilization of all other borders was performed using the harmonic scalpel.

Results:   Time of surgery was 100 minutes. Histology revealed a rare case of adrenal cavernous haemangioma. Postoperative follow up after 6 months was normal.

Conclusion:   Despite comprehensive preoperative work‐up adrenal lesions may present with rare unexpected histologies, including neurogenic tumours, myelolipoma, metastases, adrenal carcinoma, or hemangioma. Adrenal hemangiomas possess a potential risk of haemorrhage, thrombosis and necrosis. Today, laparoscopic adrenalectomy is the safe and effective treatment of choice for benign tumours and isolated metastases. Operative time and complexity are reduced by using the harmonic scalpel. Incidentalomas larger than 4 cm should be resected laparoscopically if no adrenal carcinoma is suspected.