No abstract

Background: A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. Methods: Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24-48 h. Results: There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. Conclusion: Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.

and PV Desmond have no conflicts of interest to declare. P De Cruz has received travel grant support from Abbott and Schering-Plough. MA Kamm has acted as an advisor to Abbott and Janssen, has received research support from Abbott, and has acted as a speaker at symposiums sponsored by Abbott and Janssen. A Hamilton has received an educational grant from Abbott. D Liew has served on advisory boards and received research grants from Abbott. IC Lawrance has been on an advisory board for Abbott and Janssen, a speaker for Abbott and Janssen, and has held research and travel grants from Abbott and Janssen. JM Andrews has been an advisory board member for both Janssen and Abbott, spoken for both Abbott and Janssen, received research funds from both Abbott and Janssen, and received travel grants from both Abbott and Janssen. PA Bampton has been on advisory boards for Janssen and Abbott, has received research funding from Abbott, and travel sponsorship from both Abbott and Janssen. PR Gibson has received consulting fees from Abbott, Janssen, and Schering-Plough; research support from Abbott; and payments for lectures from Abbott and Janssen. FA Macrae has been on an advisory board to Janssen, has received travel grants from Abbott, and has received clinical research support from Janssen, Abbott and MSD. W Selby has been on an advisory board for Abbott. SJ Bell has received travel assistance from Abbott. SJ Brown has received travel support and speaker fees from both Abbott and Janssen. WR Connell has been on advisory board for Janssen and a speaker for Abbott and Janssen. AS Day has been an M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT advisor to Janssen. RB Gearry has been on an advisory board for Abbott and Janssen, a speaker for Abbott and Janssen, and held research, educational and travel grants from Abbott and Janssen.

Internal fistulas in diverticular disease are uncommon and have a reputation of being difficult to treat. Eighty four patients treated from 1960 to April 1986, representing 20.4 percent (84 of 412) of the surgically treated diverticular disease patients, were reviewed. Eight patients had multiple fistulas. Sixty-five percent (60 to 92) of fistulas were colovesical, 25 percent (23 of 92) colovaginal, 6.5 percent (6 of 92) coloenteric, and 3 percent (3 of 92) colouterine fistulas. There were 66 percent (35 of 53) males and 34 percent (18 of 53) females with colovesical fistulas only. Hysterectomies had been performed in 50 percent (12 of 24) and 83 percent (19 of 23) of females with colovesical and colovaginal fistulas, respectively. Operative management included: resection anastomosis, resection with anastomosis and diversion, Hartmann procedure, and three-stage procedure. In the latter half of the series there was a significant decrease in staging procedures with no significant statistical difference in complications. There were three deaths (3.5 percent) in the series. Other complications included: wound infection, 21 percent (18 of 84), enterocutaneous fistula, 1 percent (4 of 84), and anastomotic dehiscence, 5 percent (4 of 84). Primary anastomosis can be performed with acceptable morbidity and mortality and today is the procedure of choice, leaving staging procedures to selected patients.

The evidence base for laparoscopic-assisted resection of colorectal malignancies is inadequate to determine the procedure's safety and efficacy. Because of inadequate evidence detailing circumferential marginal clearance of tumors and the necessity of determining a precise incidence of cardiac and other major complications, along with wound and port site recurrence, it is recommended that a controlled clinical trial, ideally with random allocation to an intervention and control group, be conducted. Long-term survival rates need to be a primary aim of such a trial.

Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.

SUMMARY BackgroundCrohn's disease recurs in the majority of patients after intestinal resection.

Patients undergoing FD for perianal Crohn's disease have <20% likelihood of restoration of intestinal continuity. This is not improved with biological therapy.