PURPOSE: Preoperative chemoradiation therapy is used widely in the treatment of rectal cancer. The predictive value of response to neoadjuvant remains uncertain. We retrospectively evaluated the impact of response to preoperative and, specifically, of T-level downstaging, nodal downstaging, and complete pathologic response after chemoradiation therapy on oncologic outcome of patients with locally advanced rectal cancer. METHODS: There were 88 patients with ultrasound Stage T3/T4 midrectal (n = 37) and low rectal (n = 51) cancers (63 males; mean age 62.6 years). All patients were treated by preoperative 5-fluorouracil-based chemotherapy and pelvic radiation followed by surgical resection in six weeks or longer (56 sphincter-preserving resections). RESULTS: T-level downstaging after neoadjuvant treatment was demonstrated in 36 (41 percent) of 88 patients, and complete pathologic response was observed in 16 (18 percent) of the 88. Of the 42 patients with ultrasound-positive nodes, 27 had no evidence of nodal involvement on pathologic evaluation (64 percent). The overall response rate (T-level downstaging or nodal downstaging) was 51 percent. At a median follow-up of 33 months, 86.4 percent of patients were alive. The overall recurrence rate was 10.2 percent (three patients had local and six had metastatic recurrences). Patients with T-level downstaging and complete pathologic response were characterized by significantly better disease-free survival (P = 0.03, P = 0.04) and better overall survival (P = 0.07, P = 0.08), according to Wilcoxon’s test comparing Kaplan-Meier survival curves. None of the patients with complete pathologic response developed recurrence or died during the follow-up period. CONCLUSION: T-level downstaging and complete pathologic response after preoperative chemoradiation therapy followed by definitive surgical resection for advanced rectal cancer resulted in decreased recurrence and improved disease-free survival. Advanced rectal cancers that undergo T-level downstaging and complete pathologic response after chemoradiation therapy may represent subgroups that are characterized by better biologic behavior.

PURPOSE: This study evaluated the effectiveness of combining advancement flap with sphincteroplasty in patients symptomatic with rectovaginal fistula and anal sphincter disruption. METHODS: Twenty patients with rectovaginal fistulas and anal sphincter disruptions after vaginal deliveries underwent combined rectal mucosal advancement flap and anal sphincteroplasty between July 1986 and July 1993. The mean age of the patients was 30 (range, 18–40) years and the mean duration of symptoms was 54.8 weeks (range, 7 weeks to 6 years). In addition to mucosal advancement flap repair, 13 patients underwent two-layer repair of anal sphincters (with reapproximation of the puborectalis in 8 of the patients); 6 patients underwent one-layer overlap repair of anal sphincters (with reapproximation of the puborectalis in 2 of the patients); and 1 patient underwent reapproximation of internal anal sphincter alone because squeeze pressures were adequate, as determined by anal manometry. RESULTS: Postoperatively, vaginal discharge of stool and flatus was eliminated entirely in all 20 patients. Perfect anal continence of stool and flatus was restored in 14 patients (70 percent). Incontinence was improved but not eliminated in six patients (4 incontinent to liquid stool and 2 to flatus), and two patients required perineal pads. Subjectively, 19 patients (95 percent) reported the result as excellent or good. There were no complications. CONCLUSION: The combination of mucosal advancement flap and anal sphincteroplasty is a safe and highly effective procedure for correcting rectovaginal fistula with sphincter disruption after obstetrical injuries.

American Society of Colon and Rectal Surgeons 95th Annual Convention Podium and Poster Abstracts June 9-14, 1996 Seattle, Washington: PDF Only

For the past decade peroral, orthograde, polyethylene glycol-electrolyte lavage solutions (PEG-ELS) have been the preferred bowel-cleansing regimens before diagnostic and therapeutic procedures on the colon and rectum. The large volume and unpalatibility of these solutions may lead to troubling side effects and poor patient compliance. PURPOSE: This study was undertaken to determine which of various colon-cleansing methods before colonoscopy would provide greater patient acceptance while maintaining similar or improved effectiveness and safety. METHODS: Three hundred twenty-nine patients undergoing elective ambulatory colonoscopy were prospectively randomized to one of three bowel preparation regimens. Group 1 received 41 of PEG-ELS (n=124). Group 2, in addition to PEG-ELS, received oral metoclopramide (n=99). Group 3 received oral sodium phosphate (n=106). All groups were evenly matched according to age and sex. RESULTS: Ninety-one percent of all patients completed the preparation received. Sixteen percent of patients suffered significant sleep loss with a bowel preparation. When comparing the three groups, there was no difference in the assessment of nausea, vomiting, abdominal cramps, anal irritation, or quality of the preparation. Compared with other preparations, oral sodium phosphate was better tolerated. More patients completed the preparation (P⩽0.001). Fewer patients complained of abdominal fullness (P⩽0.001). More patients were willing to repeat their preparation (P⩽0.02). Also, sodium phosphate was found to be four times less expensive than either of the PEG-ELS preparations. CONCLUSION: All regimens were found to be equally effective. Abdominal symptoms and bowel preparation were not influenced by the addition of metoclopramide. The oral sodium phosphate preparation was less expensive, better tolerated, and more likely to be completed than either of the other preparations.

For the past decade peroral, orthograde, polyethylene glycol-electrolyte lavage solutions (PEG-ELS) have been the preferred bowel-cleansing regimens before diagnostic and therapeutic procedures on the colon and rectum. The large volume and unpalatibility of these solutions may lead to troubling side effects and poor patient compliance.This study was undertaken to determine which of various colon-cleansing methods before colonoscopy would provide greater patient acceptance while maintaining similar or improved effectiveness and safety.Three hundred twenty-nine patients undergoing elective ambulatory colonoscopy were prospectively randomized to one of three bowel preparation regimens. Group 1 received 41 of PEG-ELS (n = 124). Group 2, in addition to PEG-ELS, received oral metoclopramide (n = 99). Group 3 received oral sodium phosphate (n = 106). All groups were evenly matched according to age and sex.Ninety-one percent of all patients completed the preparation received. Sixteen percent of patients suffered significant sleep loss with a bowel preparation. When comparing the three groups, there was no difference in the assessment of nausea, vomiting, abdominal cramps, anal irritation, or quality of the preparation. Compared with other preparations, oral sodium phosphate was better tolerated. More patients completed the preparation (P < or = 0.001). Fewer patients complained of abdominal fullness (P < or = 0.001). More patients were willing to repeat their preparation (P < or = 0.02). Also, sodium phosphate was found to be four times less expensive than either of the PEG-ELS preparations.All regimens were found to be equally effective. Abdominal symptoms and bowel preparation were not influenced by the addition of metoclopramide. The oral sodium phosphate preparation was less expensive, better tolerated, and more likely to be completed than either of the other preparations.

Introduction and Objectives: The minimally invasive infrapubic inflatable penile implant procedure was developed by Dr Perito with the aim of minimising operative time and post-operative morbidity. Dr Eid has also demonstrated a significant reduction in postoperative infections with his No-Touch technique. We have developed a new technique that combines key aspects of these 2 approaches to create a minimally invasive, no-touch (“MINT”) technique for penile prosthesis insertion. We theorised that the MINT technique would take advantage of the benefits that each of these established approaches offered and therefore our primary aims were to assess feasibility, safety, post-operative infection rate and revision rate. Methods: The principles of the MINT technique involve an infrapubic approach combined with a no-touch technique facilitated by using 2 standard surgical drapes (19 clear non-adhesive drape and 19 Ioban drape) and an Alexis wound retractor (figure 1). We present results for our first 258 consecutive patients undergoing primary prosthesis implantation from May 2012 to July 2017, and followed-up for at least 3 months. Patients with complex surgery necessitating >1 incision were excluded. Data was collected using a prospective database. This is the largest penile implant series with the longest follow up to be published in Australia. Results: Average age ( SD) was 60.8 ( 10.3) years. Patients had one or more of the following aetiologies for erectile dysfunction: vascular disease (n = 121), post-radical prostatectomy (n = 142), diabetes (n = 80), Peyronie’s disease (n = 60), venous leak (n = 17) and priapism fibrosis (n = 4). Implant used: Coloplast Titan (n = 246), Genesis (n = 6), American Medical Systems (LGX; n = 5), (CX; n = 1). The average ( SD) cylinder and rear tip extender length was 19.45 ( 1.8) and 1.0 ( 0.8) cms respectively. Median (IQR) follow-up was 30.6 (16.8, 45.7) months. There has been 3 (1.2%) complications: one patient had prosthetic infection after prolonged post-op catheter, which was salvaged. 2 patients had urethral perforation which was repaired intra-operatively, but had a post-operative infection. One of these 2 patients had a prosthesis explant and the other patient management is ongoing. There were also 18 (7%) non-infection related ancillary procedures: 11 pump revisions, 2 corporoplasties, 2 prosthesis revisions, 1 revision of reservoir, 1 glanspexy, and 1 prosthesis explant due to pain with no clinical or laboratory signs of infection. Conclusions: The MINT technique for penile implant surgery is a safe and feasible procedure with a 1.2% infection rate and 7% revision rate in our first consecutive 258 patients with 30.6 months median follow-up. Notably, there were no infections unrelated to procedure complication, that is, no infections the standardised MINT technique.

American Society of Colon and Rectal Surgeons 91st Annual Convention Podium and Poster abstracts: PDF Only

The effect of intravenous histamine on intragallbaladder pressure (GBp) and subsequent modification of the histamine response by H1-and H2-antagonists was investigated in an awake baboon model. Responses to specific H1-and H2-agonists were also examined in order to further elucidate gallbladder histamine responses. Gallbladder volume (GBv) was arbitrarily set at 60–70% of observed resting GBv, and drugs were then infused intravenously with continuous monitoring of GBp. Histamine administration resulted in a logarithmic dose-response curve with a maximal increase in GBp equal to 31.7 mm Hg at a dose of 0.0625 mg of histamine. Infusion of the H1-antagonist diphenhydramine hydrochloride (Benadryl) resulted in a decreased GBp response to histamine when compared to preblocker response at all doses studied. On the other hand, histamine response following administration of the H2-antagonist metiamide was significantly greater than the preblocker histamine response. Infusion of the H1-agonist 2-pyridylethylamine resulted in a dose-dependent increase in GBp similar to the histamine curve, while infusion of the H2-agonist dimaprit resulted in consistent decreases in GBp. These results extend previous observations in subprimate preparations and demonstrate the presence of both stimulatory H1-receptors and inhibitory H2-receptors in anin situ primate model.