No abstract

The grade of a tumour is gauged on the subjective assessment of a number of histopathological parameters. The problems associated with this exercise were viewed from a historical perspective and survival analysis of 447 patients receiving surgery for rectal adenocarcinoma was undertaken. Only deaths from rectal adenocarcinoma were included as events in the survival analysis. Seven grade-related parameters were scored by one observer. A grading system was constructed using the Cox regression model. The variables in the best-fitting parsimonious model comprised lymphocytic infiltration, tubule configuration and pattern of growth. Scores were derived from the model and a four grade system was created in which the groups were of similar size. Good reproducibility of the selected histopathological parameters was demonstrated. Grade-related parameters were then allowed to compete with stage-related parameters in an overall model of pathological prognostic categories. The parameters selected in the best model were number of affected lymph nodes, the presence of lymphocytic infiltration and extent of spread through bowel wall. A set of five prognostic categories was developed from this model.

Aim Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures.Method In a pragmatic, factorial (2 9 2) design trial, patients could be randomised between abdominal and perineal surgery (i), and suture vs resection rectopexy for those receiving an abdominal procedure (ii) or Altemeier's vs Delorme's for those receiving a perineal procedure (iii). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores (Vaizey, bowel thermometer and EQ-5D) measured up to 3 years.Results Two hundred and ninety-three patients were recruited: 49 were randomised between surgical approaches (i); 78 between abdominal procedures (ii); and 213 between perineal procedures (iii). Recurrence rates were higher than anticipated, but not significantly different in any comparison: Altemeier's vs Delorme's 24/102 (24%) and 31/99 (31%) [hazard ratio (HR) 0.81; 95% CI 0.47, 1.38; P = 0.4]; resection vs suture rectopexy 4/32 (13%) and 9/35 (26%) (HR 0.45; 95% CI 0.14, 1.46; P = 0.2); perineal vs abdominal 5/25 (20%) and 5/19 (26%) (HR 0.83; 95% CI 0.24, 2.86; P = 0.8). Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons.Conclusion No significant differences were seen in any of the randomised comparisons, although substantial improvements from baseline in quality of life were noted following all procedures.

Between 1957 and 1985, 886 women with Crohn's disease and an intact distal large bowel were seen at St. Mark's Hospital. Ninety of these patients developed a fistula between the vagina and anus or rectum at an average age of 34 years. The track of the fistula was clearly documented in 80 patients and was extrasphincteric or suprasphincteric in 36, transsphincteric in 42 (high 13, low 29), and superficial in two. Of the 90 patients, 12 (13 percent) were managed throughout without recourse to surgery. Twelve (13 percent) had the fistula laid open or drainage of an abscess as the only surgery. Twelve (13 percent) underwent repair of the fistula and, of these, eight remain symptomatically cured. One has had further symptoms but no surgery while three later underwent proctectomy for rectal disease. In eight patients the colon was removed and the rectum defunctioned and in 34 the rectum was excised as the initial surgery after development of the fistula. The remaining 12 (13 percent) underwent later proctectomy for rectal disease or failed conservative management of the fistula. Extensive colonic involvement, rectal disease, or associated anal lesions were the main reasons for rectal excision in 38 patients. In only ten was the rectovaginal fistula a prominent indication for proctectomy. As medical treatment, repair, or other local surgery were successful in one third of the patients, these options should always be considered in the first instance.

Anal endosonography has been performed in 22 patients with fistula in ano and perianal sepsis and compared with the operative findings. Using a special hard cone attachment to a radial 7 MHz probe the examination was well tolerated, rapid and generally accurate, detecting two unsuspected foreign bodies and all seven complicated fistula in ano preoperatively.