Can normalized carcinoembryonic antigen following neoadjuvant chemoradiation predict tumour recurrence after curative resection for locally advanced rectal cancer?

AIM

The aim of this work was to evaluate whether normalized carcinoembryonic antigen (CEA) following neoadjuvant chemoradiation predicts the prognosis following curative resection in locally advanced rectal cancer.

METHOD

Patients who underwent neoadjuvant chemoradiation and curative resection for locally advanced rectal cancer between 2010 and 2015 were divided into three groups: Group A (n = 119, normal-to-normal): normal CEA before and after neoadjuvant chemoradiation; Group B (n = 37, high-to-normal): elevated CEA before and normal CEA after neoadjuvant chemoradiation; Group C (n = 36, high-to-high): elevated CEA before and after neoadjuvant chemoradiation. Overall and disease-free survival were compared. Univariate and multivariate analyses identified potential predictors for recurrence.

RESULTS

One hundred and ninety two patients [median age 59 years (range 31-87), 65.1% male] were identified: 54.7% had low rectal cancer: 12.5% were clinical stage T4 and 70.3% were clinically node positive; 21.9% achieved complete pathological response; 24.5% had abdominoperineal resection (APR); and 70.3% underwent adjuvant chemotherapy following curative resection. Significantly more patients in Group C underwent APR (p = 0.0209), had advanced pathological T stage (P = 0.0065) and a higher prevalence of perineural invasion (p = 0.0042). Overall and disease-free survival were significantly higher for Group A than for Group C [hazard ratio (HR) = 4.32, 95% CI = 1.66-11.21, p = 0.0026 and HR=2.68, 95% CI = 1.33-5.40, p = 0.0057, respectively]. No significant difference was noted between Groups A and B for overall (p = 0.0591) or disease-free (p = 0.2834) survival. Another risk factor associated with recurrence and death was clinical T4 stage; nodal positivity was a risk factor only for recurrence.

CONCLUSION

Elevated CEA after neoadjuvant chemoradiation and clinical stage T4 disease were unfavourable predictors for overall and disease-free survival. Normalized CEA during neoadjuvant chemoradiation may serve as a prognosticator, although pretreatment CEA may significantly affect survival.

Anal dysplasia as an incidental finding: the importance of specimen evaluation

AIM

The incidence of anal squamous cell carcinoma (SCC) has increased dramatically in the USA. The squamous intraepithelial lesion has been identified as a precursor lesion to SCC, stratifying the abnormality into low grade or high grade. There have been studies on the prevalence of incidentally found SCC in haemorrhoidectomy specimens, but there are no studies to date on the incidence of dysplasia. The purpose of this study was to establish a baseline incidence of dysplasia that provides helpful information for future epidemiological studies.

METHODS

This is a retrospective review of patients who underwent haemorrhoidectomy from 2005 to 2019. Pathology regarding the type of dysplasia, medications, and diagnoses that may predispose to immunosuppression were collected.

RESULTS

In all, 810 patients with a mean age of 51.7 (range 20-91) years underwent haemorrhoidectomy. Eighteen (2.2%) of the patients had abnormal pathology (low-grade squamous intraepithelial lesion, 3; high-grade squamous intraepithelial lesion, 12; SCC, 2; adenocarcinoma, 1). Thirty-seven (4.5%) of the entire cohort had some risk factors for immunosuppression: chronic steroid use (nine), human immunodeficiency virus (HIV) (13), biologic medications (six), transplant recipients (two) and immunocompromising diseases (four). Only 4/18 patients had an immunosuppression risk in that all four of these patients were HIV-positive. Surveillance following excision was undertaken for an average of 6 (range 1-12) months, during which time four patients underwent a repeat biopsy.

DISCUSSION

Anal dysplasia found in an otherwise asymptomatic population has a prevalence of 2.2%. This finding supports the routine examination of benign anorectal specimens undergoing microscopic examination. Interestingly, the majority of the patients identified had no immunosuppressant risk factors.

Ureteral Injury During Colorectal Surgery: Two Case Reports and a Literature Review

Iatrogenic ureteral injury (IUI) is a dreaded complication of abdominopelvic surgery. Although rare, it is associated with severe consequences. This complication most commonly occurs during gynecological procedures but may also occur during colorectal surgeries. We present two cases of IUI in patients in whom the ureteric stents were electively placed. The first case was a 71-year-old male with no significant medical history. The patient underwent an elective laparoscopic sigmoidectomy for complicated diverticulitis. During the procedure, a proximal IUI occurred, and was recognized and repaired. The second case occurred in a 68-year-old male with a history of multiple complicated abdominal surgeries. The patient underwent a second redo low anterior resection for a long preanastomotic stricture. The IUI occurred in the right fibrosed presacral plane, approximately 3 cm proximal to the bladder. The ureter was reimplanted to the bladder during the same procedure. We will also present a literature review of IUI, including the risk factors, intraoperative prevention, and repair options.

Colorectal Cancer Screening: Do We Practice What We Preach?

Objective: Compliance rates for colorectal cancer screening have been reported as low, and ignorance is the most common factor sighted to explain this. The aim of this study was to determine screening compliance among colorectal surgeons assumed to be educated of the risks of colorectal cancer. Methods: A postal survey was distributed to the members of the American Society of Colon and Rectal Surgeons. Results: A total of 1195 members were surveyed. All respondents indicated that they advocate screening. Colonoscopy every 10 years and annual fecal occult blood testing were the most common strategies advocated to individuals with baseline risk. Colonoscopy every 5 years and annual fecal occult blood testing were the most common strategies advocated to patients with a first-degree relative with polyps or cancer. Most of these colorectal surgeons initiated their screening before 50 years of age. Conclusion: Colorectal cancer screening compliance is high among members of the American Society of Colon and Rectal Surgeons. These rates may be the result of awareness of the risks of colorectal cancer.

Biofeedback Therapy After Perineal Rectosigmoidectomy or J Pouch Procedure

The aim of this study was to determine the outcome and to identify possible predictors of success for biofeedback therapy after perineal rectosigmoidectomy (PRS) or coloanal or ileoanal J pouch. A retrospective chart review of all patients with electromyography-based biofeedback therapy due to fecal incontinence after PRS or a J pouch procedure was undertaken. Follow-up was obtained by telephone survey. Fourteen patients (4 men and 10 women) were included in this study. In the 9 patients after PRS, the frequency of daily bowel movements was 3.6 2.8 preoperatively, 4.1 3.2 prebiofeedback, and 2.2 - 1.3 postbiofeedback (P < .05). The frequency of daily incontinent episodes was reduced from 2.4 2.2 preoperatively and 2.0 + 1.9 prebiofeedback to 0.26 0.3 postbiofeedback (P< .05). The incontinence scores decreased from 17 3.1 preoperatively to 16 + 2.1 prebiofeedback and to 8.2 5 postbiofeedback (P < .001). At a follow-up of 15.8 7.1 months, 5 patients after the J pouch had decreased daily bowel frequency from 6.6 4.2 prebiofeedback to 3.3 2 postbiofeedback and 3.1 2 at follow-up (P < .05). The frequency of daily incontinent episodes was reduced from 1.9 1.3 prebiofeedback to 0.9 0.7 postbiofeedback to 0.7 0.8 at followup (P < .05). The incontinence scores decreased from 13.4 2.7 prebiofeedback to 8.8 5.1 postbiofeedback to 6.8 5.5 at follow-up (P < 0.05). In both groups, the postbiofeedback incontinence score correlated with the prebiofeedback incontinence score. Furthermore, there was no correlation between outcome and age, interval between surgery and biofeedback therapy, frequency of biofeedback sessions, or manometry results in either group. Biofeedback therapy is an effective option for patients with fecal incontinence after perineal rectosigmoidectomy or colonic or ileal J pouch.

Formalin Instillation for Hemorrhagic Radiation Proctitis

Although formalin instillation has been proven to be an effective treatment of hemorrhagic radiation proctitis, different tech niques with varying success rates have been reported. The aim of this study was to assess our experience with formalin instillation for the treatment of radiation proctitis. After Institutional Review Board approval, all patients who presented with radiation proctitis and were treated with 4% formalin instillation were identified from a prospective database. Techniques of instillation were as follows: a formalin-soaked sponge stick was applied via a proctoscope (SS) and placed at each quadrant with a mean contact of 2.5 minutes (range, 0.5-3 minutes), or the formalin solution was introduced through a proctoscope in aliquots for a total of 350 to 400 mL irrigation (IR), with a mean contact time of 30 seconds in each aliquot. The patients were divided into two groups according to the method of formalin instillation and their outcomes were compared. Between March 1995 and September 2003, 21 patients who underwent formalin treatment were identified: 17 patients were in the SS and 4 patients were in the IR group. The mean age was 74.8 6.4 years and 70.5 6.8 years and the male/female ratio was 16:1 and 3:1 in the SS and IR groups, respectively. Indications for radiation therapy were prostate cancer in 19 patients: 16 (95.1%) SS patients and 3 (75%) IR patients. Four (23.5%) patients in the SS group were receiving anticoagulants or antiplatelet medications before the procedure. The mean duration of bleeding before formalin instillation was 11.7 months (range, 2-48 months) in the SS and 10.5 months (range, 7-12 months) in the IR group. Sixteen (94.1%) patients in the SS and 4 (100%) in the IR group had previous treatments for radiation proctitis, including hydrocortisone enema, 5-aminosalicylate mesalamine, and endoscopic coagulation. Eight (47.1%) patients in the SS and 2 (50%) in the IR group received a preprocedural blood transfusion, and 1 patient in the SS group required a blood transfusion after the formalin instillation. This patient subsequently underwent restorative proctosigmoidectomy because of persistent bleeding. The mean length of the procedure was 27.1 10.8 minutes in the SS group and 22.5 6.5 minutes in the IR group. The bleeding was successfully stopped on the first attempt in 14 patients (82.4%) in the SS group and 3 (75%) in the IR group. The instillation was repeated in 1 patient (5.9%) in the SS group and in 1 (25%) in the IR group. Four patients (23.5%) in the SS group experienced rectal pain after the procedure. One patient (5.9%) developed a new onset of fecal incontinence, while another (5.9%) had anococcygeal pain accompanied by worsening of fecal incontinence. One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months). Formalin instillation is effective in controlling refractory hemorrhage secondary to radiation proctitis.

Pouch Perineal Rectosigmoidectomy: A Case Report

Many surgical methods have been described for the treatment of full-thickness rectal prolapse. Rarely, unusually large lengths of colon must be excised, thus resulting in a significant loss of the absorptive function of the remaining colon. We present an unusual case in which an extraordinary length of the colon was excised and a perineal reservoir was created in the form of a colonic J-pouch to improve continence.

Accuracy of hydrogen peroxide enhanced endoanal ultrasonography in assessment of the internal opening of an anal fistula complex

BACKGROUND

The aim of this study was to evaluate the accuracy of hydrogen peroxide-enhanced ultrasound in localizing the internal opening of the anal fistula.

METHODS

A retrospective review of all patients with anal fistula who underwent hydrogen peroxide-enhanced ultrasound was performed. The results of hydrogen peroxideenhanced ultrasound and intraoperative findings on the basis of operative reports were correlated.

RESULTS

A total of 57 patients (47 men) of mean age of 45.7 (range, 21-77) years underwent hydrogen peroxide-enhanced ultrasound with a diagnosis of anal fistula; 36 patients underwent surgery. The intraoperative internal opening correlated with the hydrogen peroxide-enhanced ultrasound report in 22 of 36 patients (61.1%). In 5 patients, the hydrogen peroxide-enhanced ultrasound yielded false-positive information with a positive predictive value of 84%. Four of the 7 patients with falsenegative hydrogen peroxide-enhanced ultrasound findings had supra- and extrasphincteric fistulas.

CONCLUSIONS

There is a 61.1% correlation between hydrogen peroxide-enhanced ultrasound and surgical findings of the internal opening with a positive predictive value of 84%. If no internal opening was seen on hydrogen peroxide-enhanced ultrasound, it strongly suggests the possibility of a supralevator or extrasphincteric fistula.

Short-term outcome of infliximab and other medications on patients with inflammatory bowel disease undergoing ileostomy reversal

AIM

We evaluated the impact of immunosuppressive drugs on the short-term outcome following loop ileostomy closure in patients with inflammatory bowel disease.

METHOD

Data on 249 patients with inflammatory bowel disease, who underwent loop ileostomy closure from 2001 to 2008, were retrospectively reviewed from a prospectively maintained database. Patients were distributed among groups according to the inflammatory bowel disease drugs used. Comorbidity, diagnosis, intra-operative and postoperative morbidity and length of stay data were analysed. Patients in group (INF) were receiving infliximab with or without other immunosuppressive agents (28), patients in group (S) were receiving only steroids (72) and those, in group III (S&I) were on steroids plus immunosuppressive agents, other than infliximab (35). Patients in group (ND) had not received any immunosuppressive agents for 2 months and served as the control group (114).

RESULTS

Postoperative complication rates (wound infection, hernia, obstruction, intra-abdominal abscess, leakage, enterocutaneous fistula and sepsis) occured in 4.0, 12.0, 14 and 17.0% of patients in the four groups (P > 0.05). Reoperation was needed in 3.0% (2) of patients in group S, 6.0% (2) in S&I and 3.0% (3) in C groups, and the mean hospital stay was 4.6 (± 2.1), 5.6 (± 4.6), 5.2 (± 4.7) and 5.2 (± 6) days in groups INF, S, S&I and ND, respectively. There was no mortality.

CONCLUSION

There were no significantly increased postoperative complications after ileostomy closure in patients who received infliximab or other immunosuppressive medications compared with patients who did not.

How reliable is laparoscopic colorectal surgery compared with laparotomy for octogenarians?

BACKGROUND

Due to the current increased longevity in the elderly population and the increased size of that population, major abdominal intervention is more frequently performed among octogenarians. This study aimed to compare the surgical and postoperative outcomes of laparoscopic colorectal resections with those of open surgery in the octogenarian population.

METHODS

Retrospective analysis based on a prospectively maintained database of octogenarians who underwent laparoscopic or open elective colorectal resections from 2001 to 2008 was performed. Diagnosis, comorbidities, operative data, and early postoperative complications are analyzed in this report.

RESULTS

Colon resection was performed for 199 octogenarians, using laparotomy for 116 patients (group 1) and laparoscopic surgery for 83 patients (group 2). The mean age was 84.3 years for the laparotomy patients and 84.7 years for the laparoscopic patients. The American Society of Anesthesiology (ASA) scores was comparable between groups 1 and 2. Colorectal adenoma was the most common indication for surgery in both groups: for 77.6% of the group 1 patients and 54.2% of the group 2 patients. Right colectomy was the most frequently performed operation in group 2: for 57.8% of the group 2 patients and 31% of the group 1 patients (p = 0.0003). Open resections had a higher mean blood loss in both group 1 (286 ml) and group 2 (152 ml) (p = 0.0002), and more patients required intraoperative transfusions (p = 0.005) despite similar operative times. The conversion rate in the laparoscopic group was 25.3%. The patients in the laparoscopic group had less morbidity, both overall and clinically, than the open group (p < 0.05). The median hospital stay was 8 days in group 1 and 6 days in group 2 (p = 0.0065). The rate of major surgical complications was similar in the two groups of patients: 6% in group 1 and 4.8% in group 2. The reoperation rate was 2.6% in group 1 and 3.6% in group 2 (p > 0.05). The mortality rate was 3.4% in group 1 and 2.4% in group 2.

CONCLUSIONS

Laparoscopic colorectal resection was effective and safe for octogenarians, with less blood loss and faster postoperative recovery. The morbidity rate is lower than for traditional laparotomy.

Conversion in laparoscopic surgery: does intraoperative complication influence outcome?

BACKGROUND

Conversion from laparoscopy to laparotomy can be expected in a variable percentage of surgeries. Patients who experience conversion to a laparotomy may have a worse outcome than those who have a successfully completed laparoscopic procedure. This study aimed to compare the outcomes of converted cases based on whether the case was a reactive conversion (RC, due to an intraoperative complication such as bleeding or bowel injury) or a preemptive conversion (PC, due to a lack of progression or unclear anatomy).

METHODS

All laparoscopic colorectal procedures converted to a laparotomy were retrospectively reviewed from data prospectively entered into an institutional review board-approved database. Patients who underwent an RC were matched with patients who underwent a PC according to age, gender, body mass index (BMI), and diagnosis. Patients who underwent a laparoscopic colorectal resection (LCR) were taken as the control group. The incidence and nature of postoperative complications, the time to liquid or regular diet, and the length of hospital stay were recorded.

RESULTS

Of 962 laparoscopic procedures performed between 2000 and 2007, 222 (23.1%) converted to a laparotomy were identified. The 30 patients who had undergone an RC were matched with 60 patients who had undergone a PC and 60 patients who had undergone an LCR. The reasons for RC were bleeding in 14 cases, bowel injury in 6 cases, ureteric damage in 3 cases, splenic injury in 3 cases, and other complications in 4 cases. The patients who had undergone RC were more likely to have experienced a postoperative complication (50% vs 27%; p = 0.028), required longer time to toleration of a regular diet (6 vs 5 days; p = 0.03), and stayed longer in the hospital (8.1 vs 7.1 days; p = 0.080).

CONCLUSION

Preemptive conversion is associated with a better outcome than reactive conversion. Based on this finding, it appears preferable for the surgeon to have a low threshold for performing PC rather than awaiting the need for an RC.

Imbrication of the external anal sphincter may yield similar functional results as overlapping repair in selected patients

OBJECTIVE

Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates.

METHOD

Patients who had external anal sphincter repair and follow up of at least 3 months were studied. Fecal incontinence was measured using the validated Wexner fecal Incontinence Scoring system (0 = perfect continence, 20 = complete incontinence); postoperative scores 0-10 were interpreted as successful, and scores of 11-20 as failures.

RESULTS

A total of 131 females who had anal sphincter repair between 1988 and 2000 were analysed. One hundred and twenty-one patients had overlapping external anal sphincter repair (group I), and 10 had external anal sphincter imbrication (group II). Indications for external anal sphincter imbrication were attenuation of the external anal sphincter without overt defect (n = 5), partial disruption of external anal sphincter with muscle fibres bridging the scar (n = 2), thick bulk of scar between the muscle edges (n = 2), and wide lateral retraction of the muscle edges (n = 1). There were no statistically significant differences between the groups relative to preoperative incontinence score (16.5 vs 16.5, P = 0.99), pudendal nerve terminal motor latency assessment (left 9.6%vs 0.0%, P = 0.19; right 13.4%vs 11.1%, P = 0.84), and extent of electromyography pathology (61%vs 47%, P = 0.30). The patients in group I were younger than those in group II (mean age 50.8 years vs. 61.7 years, respectively; P = 0.052) and the length of follow-up was significantly longer (32.3 months vs 14.3 months, respectively; P < 0.0001). Both procedures had similar success rates (59.5%vs 60%; P = 0.98).

CONCLUSION

Imbrication of the external anal sphincter may yield similar results as overlapping external anal sphincter repair in patients with incomplete external anal sphincter disruptions, external anal sphincter attenuation, and in patients presenting with wide lateral retraction of the muscle edges.

Prophylactic ureteric catheters in laparoscopic colorectal surgery

BACKGROUND

The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure.

METHODS

Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed.

RESULTS

Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group.

CONCLUSION

Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Slow transit constipation: a review of a colonic functional disorder

Constipation is a common gastrointestinal complaint that can cause significant physical and psychosocial problems. It has been categorized as slow transit constipation, normal transit constipation, and obstructed defecation. Both the definition and pathophysiology of constipation are unclear, but attempts to describe each of the three types have been made. Slow transit constipation, a functional colonic disorder represents approximately 15 to 30% of constipated patients. The theorized etiologies are disorders of the autonomic and enteric nervous system and/or a dysfunctional neuroendocrine system. Slow transit constipation can be diagnosed with a complete history, physical exam, and a battery of specific diagnostic studies. Once the diagnosis is affirmed and medical management has failed, there are several treatment options. Biofeedback, sacral nerve stimulation, segmental colectomy, and subtotal colectomy with various anastomoses have all been used. Of those treatment options, a subtotal colectomy with ileorectal anastomosis is the most efficacious with the data to support its use.

Faecal incontinence in male patients

OBJECTIVE

Data concerning faecal incontinence (FI) in men are lacking. The aim of this study was to evaluate the historical aetiology and contrast aetiologies in younger and older men suffering from FI.

METHOD

After institutional review board approval, a retrospective chart review was undertaken of all patients with FI seen between 1999 and 2005. The data of male patients was further analysed to assess the impact of age and historical aetiology on FI.

RESULTS

A total of 404 males were included, 203 patients were <70 years of age (group A) and 201 patients were >or=70 years of age (group B). The most common prior diagnosis in group A was perianal sepsis in 23 (11.3%) patients and symptomatic haemorrhoids in 20 (9.9%) patients; in group B it was prostate cancer in 57 (28.4%) patients, symptomatic haemorrhoids in 31 (15.4%) patients and neurological diseases in 18 (9%) patients. The most common prior procedure in group A was restorative proctectomy/proctocolectomy in 32 (15.8%) patients, fistulotomy or haemorrhoidectomy in 21 (10.3%) and 19 (9.4%) patients respectively. In group B, radiation therapy for prostate cancer was utilized in 48 (23.9%) patients and haemorrhoidectomy in 29 (14.4%) patients. Comparing group A and group B relative to diagnosis - perianal sepsis, perineal trauma, congenital disorders, HIV infection and anal cancer were more common in group A, whereas prostate cancer, neurological diseases and colon cancer were significantly more common in group B.

CONCLUSION

Prostate cancer, symptomatic haemorrhoids, perianal sepsis, rectal cancer and a history of restorative rectal resection were common associations with FI in men. The aetiologies for FI in men vary with age.

Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is a rare disorder often misdiagnosed as a malignant ulcer. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless, the endoscopic and clinical presentations may be confusing. The aim of the present study was to assess the clinical findings, surgical treatment, and outcomes in patients who suffer from SRUS.

MATERIALS AND METHODS

A retrospective chart review was undertaken, from January 1989 to May 2005 for all patients who were diagnosed with SRUS. Data recorded included: patient's age, gender, clinical presentation, past surgical history, diagnostic and preoperative workup, operative procedure, complications, and outcomes.

RESULTS

During the study period, 23 patients were diagnosed with SRUS. Seven patients received only medical treatment, and in three patients, the ulcer healed after medical treatment. Sixteen patients underwent surgical treatment. In four patients, the symptoms persisted after surgery. Two patients presented with postoperative rectal bleeding requiring surgical intervention. Three patients developed late postoperative sexual dysfunction. One patient continued suffering from rectal pain after a colostomy was constructed. Median follow-up was 14 (range 2-84) months.

CONCLUSION

The results of this study show clearly that every patient with SRUS must be assessed individually. Initial treatment should include conservative measures. In patients with refractory symptoms, surgical treatment should be considered. Results of anterior resection and protocolectomy are satisfactory for solitary rectal ulcer.

Do elderly patients benefit from laparoscopic colorectal surgery?

BACKGROUND

The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients.

AIM

To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP).

METHODS

A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age >or= 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality.

RESULTS

641 patients (M/F - 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) - p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3-17) days versus 8.7 (4-22) days in group B (p <0.0001), and LAP: 5.3 (2-19) days versus 6.4 (2-34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003).

CONCLUSIONS

Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

Squamous cell carcinoma of the rectum in ulcerative colitis: case report and review of the literature

The majority of colorectal carcinomas diagnosed are adenocarcinomas. Squamous cell carcinomas (SCC) of the rectum are rare tumors, and were reported as rare complication of inflammatory bowel disease. Surgery is the most effective therapy; and adjuvant chemotherapy and radiotherapy should also be considered. We report two cases of ulcerative colitis-associated SCC of the rectum. The lesions were treated with chemoradiotherapy with complete response.

Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness

BACKGROUND

Numerous studies have demonstrated the feasibility of laparoscopy in the management of acute adhesive small-bowel obstruction (AASBO). However, comparative data with laparotomy are lacking. The aim of this study was to compare laparoscopy and laparotomy for the treatment of AASBO in terms of patient outcome and cost-effectiveness.

METHODS

A retrospective chart review of all patients who underwent surgery for AASBO from 1999 to 2005 was conducted. Data recorded included operative and postoperative course, among others. Operative and total hospital charges were estimated from the Patient Accounting System.

RESULTS

Thirty-one patients who underwent laparoscopy were matched to a similar group of patients who underwent laparotomy. In the laparoscopy group, four patients (13%) had a laparoscopy-assisted procedure and ten patients (32%) were converted. The laparoscopy group was subdivided into laparoscopy, laparoscopy-assisted, converted, and assisted-converted subgroups. In the majority of the patients, AASBO was secondary to a single band. Overall morbidity was significantly higher in the laparotomy group (p = 0.007). Morbidity rates were statistically significant between the laparoscopy and assisted-converted subgroups (p = 0.0001) but not between the laparotomy group and assisted-converted subgroup (p = 0.19). Median hospital stay and median time to first bowel movement were significantly shorter in the laparoscopy group. Charge data were available for only the last three years of the study. Operative charges and total hospital charges were similar between the laparoscopy and the laparotomy groups (p = 0.14 and p = 0.10, respectively). There was a significant difference in total hospital charges between the laparoscopy subgroup and laparotomy group (p = 0.03).

CONCLUSIONS

Laparoscopy for AASBO is associated with reduced hospital stay, early recovery, and decreased morbidity. Laparoscopy-assisted and converted surgeries do not differ significantly from laparotomy in regard to patient outcome. Operative and total hospital charges are similar for both laparoscopy and laparotomy.

Should ileoanal pouch surgery be staged for patients with mucosal ulcerative colitis on immunosuppressives?

INTRODUCTION AND OBJECTIVE

Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery.

MATERIALS AND METHODS

A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis.

RESULTS

Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate.

CONCLUSION

This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery.

Correlating the Fecal Incontinence Quality-of-Life Score and the SF-36 to a proposed Ostomy Function Index in patients with a stoma

Quality of life is affected by the creation of a stoma. To assess the validity of the Ostomy Function Index in patients with a stoma, a prospective survey was conducted from July 2000 to September 2001 among patients participating in local United Ostomy Association chapters (N = 99; 55 with a colostomy and 44 with an ileostomy). The Short Form 36 general health survey, Fecal Incontinence Quality of Life Scale, and the proposed Cleveland Clinic Florida Ostomy Function Index were used to assess general health and stoma function in patients with an ostomy. The average proposed function index score (7 = excellent function, 35 = poor function) was 11.97 (range 7 to 22). The proposed function Index correlated with the Fecal Incontinence Quality of Life Scale and the physical and mental component scales of the SF-36 (P < 0.05). The correlation between the proposed function index and the Fecal Incontinence Quality of Life Scale was stronger in colostomy than in ileostomy patients. With the exception of the SF-36 role-emotional domain in ileostomy patients, the function index correlated with all SF-36 scales (P <0.05) in both patient groups. The results of this study suggest that ostomy function is variable and correlates with quality of life and that the Fecal Incontinence Quality of Life Scale offers a limited assessment of quality of life in colostomy patients. The Cleveland Clinic Florida Ostomy Function Index offers an objective assessment of ostomy function that reflects on quality of life. Additional studies to refine measurement of quality of life in stoma patients are warranted.

Outcome of parastomal hernia repair with and without midline laparotomy

BACKGROUND

Surgical options for parastomal hernia (PSH) repair are primary fascial, mesh repair, and relocation with or without midline laparotomy. Overall, recurrence rates are higher after fascial repairs than after relocation. However, stoma relocation may require a midline laparotomy with higher associated morbidity. The aim of this study was to assess the outcome of PSH repair with relocation with or without a midline laparotomy.

METHODS

All patients who underwent PSH repair with relocation were identified from a clinical database. Data were collected by retrospective review of medical records including patient demographics, presenting symptoms, predisposing factors, type of surgery, postoperative complications, recurrence, and follow-up. Patients were divided into two subgroups, with or without a midline laparotomy. In patients without a laparotomy, the stoma was intraperitoneally mobilized, passed behind the abdominal wall, and delivered and matured through a premarked stoma site, across the midline.

RESULTS

Between 1992 and 2001, a total of 27 patients underwent PSH repair with relocation of the stoma to the opposite side of the abdominal wall. Of these, the operation was performed without a midline laparotomy in 11 patients (41%). There were no significant differences in age, gender, body mass index, and the duration of hernia between the non-laparotomy and laparotomy groups. Prior abdominal surgery was recorded for 3 patients in the group without a laparotomy and for 9 patients in the group with a laparotomy (p=NS). Although not quantified, patients in the non-laparotomy group were less likely to have significant intraabdominal adhesions. Conversely, patients in the laparotomy group had more advanced adhesions. The operative time was longer in the group with a laparotomy than in the group without [96.8 (50-220) minutes vs. 123.9 (45-360) minutes; (p=NS)], and the mean hospital stay was significantly less in patients without vs. with a laparotomy [5.5 (SD=1.6) days vs. 9.5 (SD=3.8) days, respectively; (p<0.05)]. There was only one recurrence in the group without a laparotomy compared to 3 in the group with a laparotomy. The mean follow-up periods were 36.8 and 56.6 months in the groups without and with a laparotomy, respectively. The postoperative complications included wound infection that occurred in 3 patients in each group.

CONCLUSIONS

PSH repair with relocation without laparotomy was associated with a significantly shorter hospital stay, possibly due to the lack of a midline abdominal wound. It may not be feasible in patients with significant intraabdominal adhesions.