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Background: The terrorist attack at Westminster Bridge on March 22nd, 2017 impacted on French high school students on a school trip in London. This terrorist attack was claimed by the Islamic State. The aim of the study was to assess the mental health consequences of the attack on the French adolescents who were directly exposed (criteria A for Post-Traumatic Stress Disorder, PTSD). This involved three dimensions, namely: (1) clinical; (2) epidemiological; and (3) prevention and therapeutic. Material and Method: The investigation was the first observational step of AVAL (Adolescents Victimes de l'Attentat de Londres) study, a cohort monitoring project and it was then a monocentric, cross sectional, non interventional survey, at only one-year post-trauma. The study was carried out utilizing self- and clinician-administered questionnaires. Volunteers from the medico-psychological emergency unit provided support for these victims during the study protocol. Results: From the target population (n = 53), 39 adolescents (73.6%) agreed to participate, with a median age 16.9 years. 12 months after the attack, 25.6% of teenagers suffered from current PTSD (p < 0.0001). Those with, vs. without, PTSD showed several significant differences: (1) heightened levels of major depressive episodes (p = 0.0266) and suicidality (p = 0.0164); (2) increased substance use, including tobacco (p = 0.0284) and cannabis (p = 0.0449); and (3) impaired functioning in school (p = 0.0203), social (p < 0.0001) and family (p < 0.0001) settings. Sixty four percentage of directly exposed teenagers also had a current psychiatric disorder other than PTSD. Discussion: The heightened levels of PTSD, psychiatric disorders, and substance use at 12 months highlight the importance of early intervention in adolescents exposed to terrorist-linked potentially traumatic events.

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AIM: Following subtotal colectomy, the retained rectal stump is a potential source of morbidity. Although restorative ileal pouch-anal anastomosis is the gold standard for ulcerative colitis, up to 14% of patients will opt for a permanent ileostomy and undergo completion proctectomy, traditionally by an abdomino-perineal approach, which itself carries significant morbidity. We describe a new technique of perineal proctectomy using transanal endoscopic microsurgery (TEMS) equipment. To our knowledge, this technique has not previously been described in the literature. METHOD: Twelve patients, mean (SD) age 66 (±13) years, underwent TEMS proctectomy, performed by a single surgeon between January 2007 and October 2011. Excision began with an intersphincteric dissection following which the TEMS (WOLF) proctoscope was inserted and close rectal dissection was performed, entering the peritoneal cavity (if the top of the stump was intraperitoneal). Following perineal extraction of the specimen, the external sphincter and skin were closed with an absorbable suture. RESULTS: Nine patients had inflammatory bowel disease, two had neoplasia and one had intractable radiation proctitis. The mean (SD) rectal stump length was 17.8 (±6.1) cm and the peritoneal cavity was entered in nine patients, with no small-bowel injury. The median postoperative hospital stay was 5.5 days. In four patients there was delayed healing of the perineal wound. There was no perioperative mortality. CONCLUSION: TEMS perineal proctectomy is a novel, but safe, technique that may avoid the need for a traditional abdominoperineal approach in selected patients.

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This case report documents the presentation and management of a 26-year-old female patient diagnosed with SEP secondary to dermoid cyst rupture. The authors postulate that acute chemical peritonitis secondary to dermoid cyst rupture can develop into SEP resulting in the clinical features depicted in this case report.

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BACKGROUND: Bowel dysfunction results in a major lifestyle disruption for many patients with severe central neurologic disease. Percutaneous endoscopic sigmoid colostomy for irrigation (PESCI) allows antegrade irrigation of the distal large bowel for the management of both incontinence and constipation. This study prospectively assessed the safety and efficacy of PESCI. METHODS: A PESCI tube was placed endoscopically in the sigmoid colon of 25 patients to allow antegrade irrigation. RESULTS: Control of constipation and fecal incontinence was improved for 21 (84%) of the 25 patients. These patients were followed up for 6-83 months (mean, 43 months), with long-term success for 19 (90%) of the patients. No PESCI had to be removed for technical reasons or for PESCI complications. Late removal of the PESCI was necessary for 2 of the 21 patients. A modified St. Marks Fecal Incontinence Score to assess bowel function before and after PESCI showed a highly significant improvement (P < 0.0001). There were no procedure-related deaths. Complications included minor sepsis at the initial PESCI tube site in four patients and bumper migration in two patients, but there were no complications related to the button device. CONCLUSION: This study showed that PESCI is a simple, safe, and effective technique for distal antegrade irrigation in the management bowel dysfunction for selected patients with central neurologic disease. A successful PESCI is very likely to continue functioning satisfactorily for a long time without technical problems or local complications.

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BACKGROUND: The aim of this study was to determine the postoperative complications of Transanal Endoscopic Microsurgery (TEMS) excision of rectal lesions. METHOD: A prospective audit of 262 consecutive TEMS procedures performed by a single surgeon between 1999 and 2008. RESULTS: The mean age of patients was 72 years. The mean area of the lesions excised was 17.5 cm(2) with a mean diameter of 4.5 cm at a mean distance of 7.4 cm from the dentate line. There were 201 full thickness excisions, 51 partial thickness excisions and nine were mixed or unclassified. Thirty-three (13%) patients developed 41 complications. There were two (0.8%) deaths within 30 days. Pelvic sepsis occurred in seven (3%) patients and was significantly more common after excision of low lesions within 2 cm of the dentate line. Postoperative haemorrhage occurred in seven (3%) patients and was significantly less common when dissection was performed with ultrasonic dissection than with diathermy. Fourteen (5%) patients developed acute urinary retention. Four (1.5%) patients developed rectal stenosis and four (1.5%) suffered uncomplicated surgical emphysema that required no treatment. CONCLUSIONS: Transanal endoscopic microsurgery is a safe operation with a low mortality and morbidity. Pelvic sepsis is more common after excision of lesions within 2 cm of the dentate line. Ultrasonic dissection is associated with less postoperative haemorrhage than diathermy.

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BACKGROUND: The outcome of local excision of early rectal cancer using transanal endoscopic microsurgery (TEM) lacks consensus. Screening has substantially increased the early diagnosis of tumours. Patients need local treatments that are oncologically equivalent to radical surgery but safer and functionally superior. METHODS: A national database, collated prospectively from 21 regional centres, detailed TEM treatment in 487 subjects with rectal cancer. Data were used to construct a predictive model of local recurrence after TEM using semiparametric survival analyses. The model was internally validated using measures of calibration and discrimination. RESULTS: Postoperative morbidity and mortality were 14.9 and 1.4 per cent respectively. The Cox regression model predicted local recurrence with a concordance index of 0.76 using age, depth of tumour invasion, tumour diameter, presence of lymphovascular invasion, poor differentiation and conversion to radical surgery after histopathological examination of the TEM specimen. CONCLUSION: Patient selection for TEM is frequently governed by fitness for radical surgery rather than suitable tumour biology. TEM can produce long-term outcomes similar to those published for radical total mesorectal excision surgery if applied to a select group of biologically favourable tumours. Conversion to radical surgery based on adverse TEM histopathology appears safe for p T1 and p T2 lesions.

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INTRODUCTION: During Transanal Endoscopic Microsurgical (TEMS) full-thickness excision of a rectal lesion above the peritoneal reflection, entrance to the peritoneal cavity is inevitable. This has been regarded as a complication that requires conversion to an open procedure. We describe our experience of full thickness intraperitoneal excision of rectal lesions where the peritoneal defect was sutured endoscopically. METHOD: Data were collected prospectively on 15 patients in whom a peritoneal defect was created intraoperatively during TEMS excision of a rectal lesion. When a defect was recognized, it was closed by endoscopic suture. If there was any doubt regarding security of the closure, a defunctioning loop stoma was fashioned. RESULTS: Between November 1998 and January 2008, a total of 257 patients underwent TEMS during which a peritoneal defect was created in 15 patients. Six patients had a defunctioning stoma formed at the time of TEMS. No patient was defunctioned postoperatively and there were no deaths. The mean hospital stay was 8 days (range 3 to 19 days). A contrast enema showed sub-clinical leaks in two patients for which no treatment was required. No patient developed pelvic or peritoneal sepsis, but one patient had to return to theatre for postoperative bleeding when a single bleeding vessel was coagulated. CONCLUSION: Full thickness excision of lesions in the intraperitoneal rectum with endoscopic suture of the defect is a safe procedure. Lesions in the upper rectum should not be excluded from TEMS excision because of the chance of peritoneal breach.

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INTRODUCTION: Before publication of the British Society of Gastroenterology and Association of Coloproctology of Great Britain and Ireland guidelines in 2002, screening for people with a family history of colorectal cancer was sporadic and largely dependant on unvalidated local guidelines. Since 1990 we have been screening patients with both high and moderate risk family histories of colorectal cancer using local protocols which were more liberal than the new guidelines. In this study, we have analysed the pathology that would have been missed if we had been using the new guidelines in the period 1990-2002. METHOD: A total of 399 consecutive patients with a positive family history of colorectal malignancy underwent screening endoscopy according to local guidelines. Demographic, endoscopic and pathologic data were prospectively collected. Patients were retrospectively divided into those who would have been screened under the new guidelines (group 1) and those who would not (group 2). The recorded pathology was graded as significant or insignificant and the findings compared between the two groups. RESULTS: A total of 399 patients underwent 557 endoscopies of which 278 (50%) were indicated under the new guidelines (group 1) and 279 (50%) were not indicated (group 2). A significant pathology or carcinoma was found in 15.8% of group 1 endoscopies and 10.0% of group 2 endoscopies. This difference was significant. CONCLUSION: If we had been using the new guidelines in the period 1990-2002, we would not have performed 279 (50%) of the 557 procedures, but would not have discovered significant pathology in 10% of the moderate risk endoscopies representing 39% of the significant pathology, which was actually present in this population.

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OBJECTIVE: Transanal endoscopic microsurgery (TEM) is a safe and effective treatment for the excision of benign rectal adenomas. In recent years it has been used for the excision of malignant lesions, although its use in this context remains controversial. The aim of this study was to investigate the local recurrence of rectal cancers following local excision by TEM. METHOD: Forty-two patients with rectal cancer were treated by TEM between 1998 and 2005. However, six patients went on to have immediate radical surgery and are excluded from the study. Of the remaining 36 the treatment intention was for cure in 16 (38.1%), compromise in 17 patients unfit for radical surgery (40.5%), and palliation in three (7.1%). RESULTS: The mean age of patients was 75 years (range 41-90). The mean lesion area was 15 cm(2) (range 0.8-42) and mean distance from the dentate line was 6.6 cm (range 0-11). The mean follow up was 34 months (range 4-94). During the follow-up period there have been eight local recurrences (22%). The recurrence rates were 26% (6/23) for pT1, 22% (2/9) for pT2 and 0% (0/4) for pT3 lesions. The mean time to recurrence was 18.3 months (range 5-42). CONCLUSION: Transanal endoscopic microsurgery is a safe procedure with obvious advantages over radical procedures. However, in this study the local recurrence rate is high. The recurrence rate may be an acceptable compromise in elderly or medically unfit patients but is hard to justify for curative intent.

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BACKGROUND: Traditionally patients with a high rectosigmoid carcinoma and a synchronous large distal rectal adenoma would be treated by low anterior resection with associated loss of rectal function. METHOD: Four patients with a carcinoma of the upper rectum or distal sigmoid colon and a synchronous distal rectal adenoma were treated by high anterior resection followed by staged Transanal Endoscopic Microsurgery (TEM) thus conserving the distal rectum. Preoperative and postoperative rectal function was assessed using the St. Mark's incontinence score. RESULTS: The proximal carcinomas and distal adenomas were 12-18 cms and 0.5-9 cms respectively from the dentate line. The mean surface area of the distal adenomas was 9.7 cms2. There were no deaths or major complications. There were no recurrences after a mean follow-up of 31.5 months. Rectal function was unchanged in three patients with a minor increase in the score in one. CONCLUSION: Staged high anterior resection and 'rEM offers effective treatment of synchronous rectosigmoid carcinoma and distal rectal adenoma with preservation of rectal function.

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OBJECTIVE: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of selected benign and malignant rectal neoplasms. It is considered a safe and effective treatment but recurrence rates of 1-13% are reported for benign lesions. The aim of this study was to assess risk factors for local recurrence of benign rectal lesions and to evaluate mortality and morbidity following TEM. METHOD: Data were prospectively collected from all patients undergoing TEM for benign adenomas from January 1998 to March 2005. The procedure was performed by a single surgeon and patients were regularly followed up. RESULTS: One hundred and forty-six procedures were included, with a median patient age of 74 years (range 22-92 years). The mean lesion area was 16 cm(2) (range 0.3-150 cm(2)) and the median distance from the dentate line was 9 cm (range 0-17 cm). Immediate complications included bleeding (six) and acute urinary retention (six). There has been one (0.68%) procedure-related death. After a median follow up of 39 months (range 4-89 months) there have been seven recurrences (4.8%), recurring at a mean time of 23.3 months (range 5-48 months). Only microscopic involvement of the circumferential resection margin was found to be significantly associated with recurrence (P = 0.0059). Recurrence was not associated with age, size of lesion, previous treatment, severity of dysplasia or use of the harmonic scalpel. CONCLUSION: TEM is a safe and effective treatment for benign rectal adenomas. Circumferential resection margin involvement is associated with recurrence, which tends to occur late. Therefore extended follow up is recommended.

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INTRODUCTION: There has been a gradual introduction of transanal endoscopic microsurgery (TEM) into UK practice although the uptake remains variable. This study aimed to assess the availability, application and referral pattern of TEM amongst colorectal surgeons. METHODS: A questionnaire was sent to all consultant members of the Association of Coloproctology. This considered their practice, the availability, application and referral pattern for TEM, and their views on application regarding a selection of rectal tumour scenarios. RESULTS: There were 142 replies representing 116 hospitals and 297 colorectal surgeons. The median catchment area was 280,000 (range 70,000-1,000,000). TEM was available in 18% of hospitals and 72% either performed or referred patents for TEM. Of 21 units performing TEM, 15 received referrals. From 305 TEM procedures performed over the previous year, 206 were referred cases. Eighty-five per cent of consultants considered TEM a necessary technique for optimum management of rectal lesions. Although 61% of consultants considered endoanal excision optimal for low benign rectal tumours, 58% said TEM was optimal for midrectal lesions and between 30% and 55% for high rectal lesions depending if the tumour position was anterior or posterior, respectively. One-third of consultants would perform TEM for a low T1 rectal carcinoma although half would proceed to anterior resection. DISCUSSION: TEM is considered to have a significant role in the optimal management of rectal lesions. The presence of the technique in a limited number of hospitals does appear to provide adequate resources although audit should continue to be centralized.

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PURPOSE: We describe the case of a 52-year woman with a 17-year history of obstructed defecation in whom all other standard treatments had failed and the patient had refused a colostomy. Her symptoms were controlled by percutaneous endoscopic colostomy with antegrade colonic irrigation. METHOD: A percutaneous endoscopic colostomy tube was placed in the sigmoid colon endoscopically using a colonoscope and the patient irrigated two liters of water through the percutaneous endoscopic colostomy twice each day and was able to successfully evacuate her rectum without excess straining or discomfort. CONCLUSION: Percutaneous endoscopic colostomy is an alternative option to colostomy in the management of obstructed defecation.

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Parastomal hernia, particularly when recurrent, presents a troublesome problem to the surgeon. Since the late 1970s, prosthetic-mesh repairs have been used increasingly, though, as yet, there is no consensus on the best technique of repair. We report a case of failure of a polypropylene-mesh repair of a recurrent parastomal hernia, complicated by erosion of the mesh edge into the colon proximal to the stoma. This entailed further resection of the colon, excision of the mesh and relocation of the colostomy. The case highlights the potential for serious morbidity from this form of repair and the need for careful assessment of symptoms before contemplating a surgical approach to any type of parastomal hernia.

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OBJECTIVE: To define the relative risk of malignant transformation in colorectal adenomas less than 10 mm in diameter. DESIGN: Prospective study. SETTING: District general hospital, UK. SUBJECTS AND MATERIALS: 1228 polyps detected endoscopically in 445 patients over the 10-year period 1989-1999. MAIN OUTCOME MEASURES: Site, size, histological type and dysplastic grade of polyp. RESULTS: 657 of the 1228 polyps were adenomas: 281 (43%) tubular, 339 (51%) tubulovillous and 37 (6%) villous. In the 357 adenomas less than 10 mm in diameter, 11 (3%) were severely dysplastic and 2 carcinomas were detected, though neither was less than 5 mm in size. The relative risk of malignancy or severe dysplasia in adenomas of 10 mm or more compared with those of less than 10 mm was 3.8 (p < 0.0001). CONCLUSIONS: Although severe dysplasia and malignancy do occur in adenomas less than 10 mm in size, they are rare in lesions of less than 5 mm. We recommend routine destruction of all polyps 5 mm or more in size, though it is not essential to remove those of less than 5 mm if they are kept under surveillance.

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