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Introduction Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting. Methods A systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma. Results Seven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies. Conclusion There remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.

Aim Previous meta-analyses of mechanical bowel preparation (MBP) before colorectal surgery have grouped colon and rectal resection together. An increased postoperative morbidity has been suggested in the absence of MBP following proctectomy. The current study used meta-analytical techniques to evaluate the comparative outcome of patients who received MBP prior to proctectomy. Method A comprehensive search was performed for published studies examining the effect of MBP before proctectomy on patient outcome. Random effects methods were used to combine data. Results Eleven studies including 1258 patients were identified. There was no significant difference in overall morbidity (OR 1.062, 95% CI 0.584–1.933, P = 0.844), anastomotic leakage (OR 1.144, 95% CI 0.767–1.708, P = 0.509), surgical site infection (OR 0.946, 95% CI 0.549–1.498, P = 0.812) or mortality (OR 1.377, 95% CI 0.549–3.455, P = 0.495) between those who did not and those who did receive MBP prior to proctectomy. Conclusion The current study did not demonstrate a beneficial effect of MBP prior to proctectomy, but the data were limited. Decision-making as to its use should be made on a case-by-case basis.

Recurrent and locally advanced colorectal cancers frequently require en bloc resection of involved organs to achieve negative margins. The aim of this review is to evaluate the most current literature related to the surgical management of locally advanced and recurrent colorectal cancer. A literature review was performed on the electronic databases MEDLINE from PubMed, EMBASE and the Cochrane library for publications in the English language from January 1993 to July 2013. The MeSH search terms ‘locally advanced colorectal cancer’, ‘recurrent colorectal cancer’ and ‘surgical management’ were used. A total of 1,470 patients with recurrent or locally advanced primary colorectal cancer were included in 22 studies. Surgical removal of the tumour with negative margins (R0) offers the best prognosis in term of survival with a 5-year survival of up to 70 %. MVR is needed in approximately 10 % with the most commonly involved organ being the bladder. The mean post-operative morbidity is 40 %, mainly relating to superficial surgical site infection, pelvic collections and delayed wound healing. Most patients will undergo radiotherapy and/or chemotherapy pre- or post-operatively. The mean 5-year overall survival for R0 resection is 50 % for recurrent and locally advanced primary tumours while survival following R1 or R2 is 12 and

Spigelian hernias are a rare abdominal wall hernia. The aim of this study was to assess the efficacy and outcomes of patients who underwent a laparoscopic spigelian hernia repair. A retrospective study was performed reviewing all patients who had a laparoscopic spigelian hernia repair. We assessed the success of the procedure including conversion rates, postoperative morbidities, and recurrence rates. Forty patents had a laparoscopic repair. Two thirds (n=25) had an intraperitoneal repair. There was no conversion to open repair. Four patients had postoperative morbidities. At 6-month follow-up all patients were pain free, with 1 recurrence. There is considerable evidence supporting the opinion that laparoscopic repair offers excellent outcomes. This report is the largest series to date, and we advocate that this approach should become the standard of care.

The incidence of locally advanced prostate cancer has decreased in the last few decades since the introduction of screening programmes. Despite earlier detection and treatment, there is still a proportion of late presentation and/or recurrences (around 10 %) of locally advanced prostate cancer. Additionally, sporadic reports of synchronous pelvic neoplasms have been published with various treatment strategies to optimize patient survival. Pelvic exenteration is a technically demanding surgical procedure that is performed for locally advanced, recurrent or synchronous pelvic malignancies. The role of pelvic exenteration in locally advanced prostate cancer has been controversial, as there is a lack of strong statistical evidence to support its role. Despite this, studies have outlined benefits of this procedure, especially in the presence of synchronous pelvic cancers or for palliative indications. Despite advances in surgical care and techniques, pelvic exenteration remains a high-risk procedure with troublesome complications. However, with better patient selection, multi-disciplinary team (tumour board) involvement and surgery being performed in specialist high volumes centres, rates of morbidity and mortality have substantially reduced.

Background Troponin estimation is increasingly performed on emergency medical admissions. We report on a high-sensitivity troponin (hscTn) assay, introduced in January 2011, and its relevance to in-hospital mortality in such patients. Aim To evaluate the impact of hscTn results on in-hospital mortality and the value of incorporating troponin into a predictive score of in-hospital mortality. Methods All patients admitted as general medical emergencies between January 2011 and October 2012 were studied. Patients admitted under other admitting services including cardiology were excluded. We examined outcomes using generalised estimating equations, an extension of generalised linear models that permitted adjustment for correlated observations (readmissions). Margins statistics used adjusted predictions to test for interactions of key predictors while controlling for other variables using computations of the average marginal effect. Results A total of 11 132 admission episodes were recorded. The in-hospital mortality for patients with predefined cut-offs was 1.9% when no troponin assay was requested, 5.1% when the troponin result was below the 25 ng/L ‘normal’ cut-off, 9.7% for a troponin result ≥25 and 1000 ng/L. The OR for an in-hospital death for troponin-positive patients was 2.02 (95% CI 1.84 to 2.21); when adjusted for other mortality predictors including illness severity, the OR remained significant at 2.83 (95% CI 2.20 to 3.64). The incorporation of troponin into a multivariate logistic predictive algorithm resulted in an area under the receiver operating characteristic curve to predict an in-hospital death of 0.87 (95% CI 0.85 to 0.88). Conclusions An increase in troponin carries prognostic information in acutely ill medical patients; the extent of the risk conferred justifies incorporation of this information into predictive algorithms for hospital mortality.

Rectal carcinoids are increasing in incidence worldwide. Frequently thought of as a relatively benign condition, there are limited data regarding optimal treatment strategies for both localized and more advanced disease. The aim of this study was to summarize published experiences with rectal carcinoids and to present the most current data.Following PRISMA guidelines, an electronic literature search performed of PubMed, Medline, Embase, and the Cochrane Library using the terms "rectum" or "rectal" AND "carcinoid" over a 20-year study period from January 1993 to May 2013. Non-English-language studies, animal studies, and studies of fewer than 100 patients were excluded. Study end points included demographic information, tumor features, intervention and outcomes. All included articles were quality assessed.Using the search parameters and exclusions as outlined above, a total of 14 articles were identified for detailed analysis. The quality of articles was low/moderate for all included scoring 9 to 17 of 27. The articles included 4,575 patients diagnosed with a rectal carcinoid. Approximately 80% of tumors were10 mm, 15% 11-20 mm, and 5%20 mm. Eight percent of patients presented with regional lymph node metastases, and 4% presented with distant metastases. Tumor size10 mm, and muscular and lymphovascular invasion are independently associated with an increased risk of metastases. The 5-year survival was 93% in patients presenting with localized disease and 86% overall.Small tumors up to 10 mm without any adverse features can be treated with endoscopic or local excision. The treatment of carcinoids between 10 and 20 mm is still contentious, but those up to 16 mm without adverse feature are suitable for local/endoscopic excision followed by careful histopathological assessment. Those20 mm or with adverse features require radical surgery with mesorectal clearance in suitable patients.