Desmond C. Winter

Appendectomy may lead to a reduction in relapses and need for medication in patients with ulcerative colitis (UC). However, the possibility of a placebo effect is still debated, as long-term prospective data are lacking. The aim of this study was to analyse the effect of an appendectomy on the clinical course of therapy refractory UC patients. In this observational prospective cohort study, a consecutive series of refractory UC patients referred for proctocolectomy between November 2012 and June 2015 were counselled to undergo laparoscopic appendectomy first. Primary endpoint was clinical response at 12 months and long-term follow-up (>2 years), defined as a decrease of ≥3 points in the partial Mayo ranging from 0 to 9. Secondary endpoints were failure (colectomy or start of new, mostly experimental medication), endoscopic remission (endoscopic Mayo score ≤1), changes in IBDQ (range 32–224), and a patient rated ‘global change’ question (“Since your operation, have your UC symptoms improved overall?”). The minimal clinically important difference (MID) in IBDQ was calculated from the difference in IBDQ change scores of the patients answering “yes” and “no” to the global change question. Statistical differences were analysed using mixed-models analysis for repeated measures applying a random-effects model. In total, 28 patients (46% female, 10 using steroids) with a median age of 41 (IQR, 33–48) underwent appendectomy with a median pre-operative partial Mayo score of 7 (IQR, 6–8). The mean baseline IBDQ was 127 (95% CI 113–141). After 12 months, 12 of 26 (46%) patients had a clinical response, none using steroids. Of those with a response, 3 of 12 refused endoscopy and 5 of 12 were in endoscopic remission. A total of 10 patients failed (6x colectomy, 4× experimental medication). For the remaining patients, the IBDQ significantly improved to mean 161 (95% CI 144–177; p < 0.001). Long-term data were available for 27 of 28 patients. After median follow-up of 4 years (range 2–5) another three patients failed (in total 9× colectomy, 4× experimental medication). Thirteen of the remaining 14 patients had clinical response (4 using steroids) of whom 6 were in endoscopic remission (endoscopy data of three patients is pending). The IBDQ was further improved to mean 169 (95% CI 151–188; p < 0.001). Overall, 77% of the patients answered “yes” to the global change question, the MID for improvement of the IBDQ was 26 points resulting in a clinical benefit for 75% of the patients. After long-term follow-up, appendectomy resulted in a clinical response in at least 48% of refractory UC patients of whom 46% were in endoscopic remission. An appendectomy could be beneficial in this patient group, as a long-term (endoscopic) placebo effect seems unlikely.

We report a rare case of Erdheim-Chester Disease, a non-Langerhans cell histiocytosis. A 60-year old female presented with a seven-month history of vague abdominal symptoms. A large retroperitoneal mass was detected on computed tomography (CT), but multiple CT-guided biopsy samples were inconclusive. Laparoscopy revealed a mass in the distal ileum, which was resected. Histology and immuno-histochemistry supported a diagnosis of Erdheim-Chester Disease.

Tailgut cysts, also known as retrorectal cystic hamartomas, are rare developmental abnormalities that typically occur in the retrorectal space. They are believed to arise from remnants of the embryonic hindgut (Hjermstad and Helwig, 1988). They can present as incidental findings during routine examination but over half of patients are thought to present with symptoms. MRI has become the modality of choice to image these frequently misdiagnosed cysts. Biopsy is not recommended. Complete intact surgical excision is advised to avoid the potential complications of these cysts which include infection, fistula formation, and the possibility of malignant transformation (Hjermstad and Helwig (1988), Mathis et al. (2010)). We describe the case of a 46-year-old female who presented with a 6-month history of low back pain. CT and MRI imaging demonstrated a complex retrorectal lesion with supralevator and infralevator components. This was removed using a combined transperineal and transabdominal approach. Histology confirmed a tailgut cyst.

Ileal pouch-anal anastomosis (IPAA) following proctocolectomy is the preferred option for patients with medically refractory ulcerative colitis, indeterminate colitis, and familial adenomatous polyposis. However, it remains a procedure associated with morbidity and mortality. Pelvic sepsis, pouch fistulae, and anastomotic dehiscence predispose to pouch failure. We report our experience with an adaptation for the formation of the stapled ileal J pouch using the GIA™ 100 stapling device (Covidien, Mansfield, Massachusetts, USA). When creating the J pouch, we remove the bevelled plastic protector from the thin fork of the stapling device, allowing the staple line to be completed to the tip of the stapled efferent limb of the pouch, thereby minimizing potential blind ending in the efferent limb and injury to the transverse staple line

A variety of approaches are available for division of major vascular structures during laparoscopic colorectal resection. Ultrasonic coagulating shears (UCS), vascular staplers, plastic or titanium clips and electrothermal bipolar vessel sealing (EBVS) are currently available. We report our experience with an EBVS device, LigaSure™ (Covidien AG), used in division of the ileocolic, middle colic and inferior mesenteric arteries during laparoscopic colorectal resection. We report the immediate outcome of 802 consecutive unselected patients who underwent elective laparoscopic colorectal cancer resection performed with use of the LigaSure™ (5 and 10 mm) at our institution over a 5-year period. Operative procedures included right hemicolectomy (n = 180), left hemicolectomy (n = 96), sigmoid colectomy (n = 347) and anterior resection (n = 179). Data were collected from a prospectively maintained cancer database and operative records. The procedures were performed primarily by three consultant surgeons with an interest in laparoscopic colorectal resection. Of 802 cases in which the LigaSure™ device was employed to divide major vascular structures, immediate effective vessel sealing was achieved in 99.8% (n = 800). Two patients experienced related adverse events both following division of the inferior mesenteric artery with a 5 mm LigaSure™. Both patients had immediate uncontrolled haemorrhage that required laparotomy. Use of the LigaSure™ device to seal and divide the major mesenteric vessels during laparoscopic colorectal resection is very effective, with a high success rate of 99.8%. Caution should be exercised in elderly atherosclerotic patients, particularly when using the 5-mm LigaSure™ device.

Is there a more privileged position than to be trusted with handling the living tissues of an anesthetized patient, a task that the patient does not supervise o

Background: A complete pathological response occurs in 10–30 per cent of patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy (CRT). The standard of care has been radical surgery with high morbidity risks and the challenges of stomata despite the favourable prognosis. This review assessed minimalist approaches (transanal excision or observation alone) to tumours with a response to CRT. Methods: A systematic review was performed using PubMed and Embase databases. Keywords included: ‘rectal’, ‘cancer’, ‘transanal’, ‘conservative’, ‘complete pathological response’, ‘radiotherapy’ and ‘neoadjuvant’. Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. Main outcome measures assessed were rates of local recurrence and overall survival, and equivalence to radical surgery. Results: Purely conservative ‘watch and wait’ strategies after CRT are still controversial. Originally used for elderly patients or those who refused surgery, the data support transanal excision of rectal tumours showing a good response to CRT. A complete pathological response in the T stage (ypT0) indicates < 5 per cent risk of nodal metastases. Conclusion: Rectal tumours showing an excellent response to CRT may be suitable for local excision, with equivalent outcomes to radical surgery. This approach should be the subject of prospective clinical trials in specialist centres.