Background Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective total mesorectal excision could reduce the adverse effects of treatment without substantially compromising oncological outcomes. We investigated the feasibility of recruiting patients to a randomised trial comparing an organ-preserving strategy with total mesorectal excision.Methods TREC was a randomised, open-label feasibility study done at 21 tertiary referral centres in the UK. Eligible participants were aged 18 years or older with rectal adenocarcinoma, staged T2 or lower, with a maximum diameter of 30 mm or less; patients with lymph node involvement or metastases were excluded. Patients were randomly allocated (1:1) by use of a computer-based randomisation service to undergo organ preservation with short-course radiotherapy followed by transanal endoscopic microsurgery after 8-10 weeks, or total mesorectal excision. Where the transanal endoscopic microsurgery specimen showed histopathological features associated with an increased risk of local recurrence, patients were considered for planned early conversion to total mesorectal excision. A non-randomised prospective registry captured patients for whom randomisation was considered inappropriate, because of a strong clinical indication for one treatment group. The primary endpoint was cumulative randomisation at 12, 18, and 24 months. Secondary outcomes evaluated safety, efficacy, and health-related quality of life assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ C30 and CR29 in the intention-to-treat population. This trial is registered with the ISRCTN Registry, ISRCTN14422743.

The current published literature supports the use of the rhomboid flap excision and the Limberg flap-repair procedures over primary midline suture techniques for the elective management of primary pilonidal disease. Further high-quality studies are necessary to compare flap with off-midline repairs.

Study characteristicsFollowing our data search in January 2018, we included 10 trials with a total of 844 participants, which we assessed using the standard Cochrane Review protocol. The trials compared the incidence of hernia development around a stoma between a group having a mesh placement at the time of stoma formation and a control group having a conventional stoma formation without mesh placement. Key resultsWe found that mesh placement around the stoma at the time of stoma formation reduces the incidence of future hernia formation. The participants having a mesh fitted had a similar level of complications as those not having a mesh. Quality of evidenceWe found low-quality evidence favouring the insertion of a mesh into people having a stoma.Prosthetic mesh placement for the prevention of parastomal herniation (Review)

, 1-12%). The rectal infiltration took the form of an anterior rectal mass with or without ulceration in 52%, an annular stricture in 45%, and separate metastasis in 3%. In 40% of patients, a preceding history of prostatic adenocarcinoma was elicited at the time of gastrointestinal presentation, while in 60% it was not elicited. In the study group, 26% of patients underwent surgery; the most commonly performed procedure was a defunctioning colostomy (18%) to alleviate symptoms of large bowel obstruction. Five patients underwent rectal resection because the pre-operative diagnosis was suspected to be primary rectal adenocarcinoma. The median survival was 15 months (95% confidence interval 14-16 months). Survival beyond 30 months was rare.

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The management of acute distal colonic obstruction remains controversial. The advent of intraoperative colonic irrigation has allowed primary anastomosis to be performed in obstructed bowel. Fifteen patients, with acute distal obstruction due to carcinoma, diverticulitis or sigmoid volvulus were managed by primary resection and anastomosis. There were two leaks (14 percent) and the duration of operation was prolonged. In an experimental study of anastomotic healing after acute obstruction, intraoperative irrigation improved early anastomotic colonic collagen content (P less than 0.02) and perianastomotic proximal and distal collagen content (P less than 0.002, P less than 0.05). Intraoperative lavage is a useful technique to permit safer primary resection and anastomosis in obstructed colon.

Ileostomy polyps are uncommon and poorly described. The aim of this study was to undertake a retrospective clinicopathological review of ileostomy polyps. Seven patients with 60 polyps arising on ileostomies performed for ulcerative colitis were studied. The histopathological evaluation of archival ileostomy biopsy specimens, polypectomy or excision specimens, and clinical review of patient records was undertaken. Fifty of 60 polyps were inflammatory cap polyps and six further polyps were composed of granulation tissue only. They occurred anywhere on the stoma at any time after ileostomy construction and were strongly associated with overt stomal prolapse. Four neoplastic polyps were identified in two patients 27-36 years after ileostomy construction; all occurred at the mucocutaneous junction. One patient presented with a 2 cm polypoid invasive adenocarcinoma while in the second a 1-7 cm polypoid mucinous adenocarcinoma and a 0.7 cm ileal tubular adenoma with high grade dysplasia occurred at the site of excision of a cap polyp showing focal low grade adenomatous dysplasia six years previously. Neoplastic and non-neoplastic polyps could not be differentiated clinically. It was found that most ileostomy polyps are inflammatory cap polyps associated with stomal prolapse. Less common are polypoid adenomas or adenocarcinomas arising at the mucocutaneous anastomosis >20 years after ileostomy construction. To prevent ileostomy carcinoma it is recommended that a biopsy of all polyps at the mucocutaneous anastomosis and of any nonprolapse associated polyps elsewhere on the stoma occurring >15 years after ileostomy construction is done. (Gut 1995; 37: 840-844)

A retrospective study was conducted on 519 patients undergoing curative resection for colorectal carcinoma between 1969 and 1980. Recurrence was diagnosed in 214 patients (41.2 percent), 179 of whom (34.5 percent) had received blood transfusions and 35 of whom (6.7 percent) had not (P less than .001). Exclusion of the right-sided colonic tumors still showed that recurrence was more common in transfused than nontransfused patients (135 [47.2 percent] vs. 25 [22.5 percent]; P less than .001). Recurrence in patients transfused only during surgery (N = 201) was higher than in nontransfused patients (P less than .001) and, similarly, all patients transfused during surgery (N = 297) had an increased risk (P less than .001). Among patients with rectal cancer, transfusion increased the risk of recurrence in those treated by abdominoperineal resection (P less than .02), but this was not the case in those treated by sphincter-saving resection (P = .2). Hierarchical log linear analysis of all dependent factors (Dukes' stage, histologic grade, age, sex, site, elective, or emergency procedure) showed that Dukes' stage and blood transfusion had the most significant effects on the development of recurrence (chi 2 = 54.04, df = 6, P less than .0001 and chi 2 = 13.93, df = 3, P less than .003). The risk of recurrence following curative surgery for colorectal cancer is markedly increased by blood transfusion on the day of operation.