Role of prophylactic ureteric stents in colorectal surgery

Ureteric injury is a feared complication in colorectal surgery, with a reported incidence of 0.2%-7.6%. Prophylactic ureteric catheter placement has the advantage of facilitating intraoperative ureter identification and assisting in immediate injury recognition and repair. However, its use has been controversial because of fear of ureteric damage during catheter insertion and postoperative urinary complications such as obstructive oliguria and urinary tract infection. Although the exact indications for prophylactic catheter placement are not clearly defined, it is generally used for reoperative cases, large tumors, previous radiation therapy, diverticulitis, fistulas, Crohn's disease and obesity. Herein, we review the incidence and risk factors for ureteric injury, the role of prophylactic ureteric stents and the complications and costs associated with its use in both open and laparoscopic colorectal surgery.

The use of molecular markers as a method to predict the response to neoadjuvant therapy for advanced stage rectal adenocarcinoma

AIM

The response to combined neoadjuvant therapy for advanced stage rectal adenocarcinoma is predictive of outcome. In addition to both clinical and pathological features, the expression of a variety of molecules may provide another method of identifying tumour responsiveness to pre-operative therapy. The aim of this study was to evaluate several markers in the apoptotic pathway as well as expression of Cox-2 and vascular endothelial growth factor (VEGF) to determine their ability to predict response to neoadjuvant therapy.

METHOD

In total, 152 patients with advanced rectal adenocarcinoma were treated with neoadjuvant therapy followed by resection. Paraffin-embedded sections obtained before and after therapy were assessed by immunohistochemical staining for Cox-2, VEGF, p53, p21, p27, Bax, BCL-2 and apoptosis protease-activating factor 1 (APAF-1). These stains were correlated with tumour regression grade, complete pathological response and T-downstaging of the surgical specimen. Clinical and pathological data were also collected. Data were analysed using the χ2 and Spearman's correlation tests.

RESULTS

Pathological complete response was seen in 24.5% of patients. Amongst the apoptosis-associated markers, only APAF-1 expression was found to be significantly associated with tumour regression grade (P<0.001), complete pathological response (P<0.031) and T-downstaging (P<0.004). On multivariate analysis, APAF-1 expression was found to be independently associated with good tumour regression grade. In contrast, overexpression of Cox-2 and VEGF in pretreatment biopsies was related to less tumour regression (P<0.003) and less likelihood of T-downstaging (P<0.03).

CONCLUSION

Immunohistochemical evaluation of initial biopsy specimens of rectal cancer with APAF-1, Cox-2 and VEGF may predict tumour response to neoadjuvant therapy in patients with advanced rectal adenocarcinoma. Those with an expected limited response may be considered for other investigational neoadjuvant protocols.

Surgical management of Crohn's disease

INTRODUCTION

Crohn's disease is an inflammatory bowel disease that can affect the entire gastrointestinal tract. It is chronic and incurable, and the mainstay of therapy is medical management with surgical intervention as complications arise. Surgery is required in approximately 70% of patients with Crohn's disease. Because repeat interventions are often needed, these patients may benefit from bowel-sparing techniques and minimally invasive approaches. Various bowel-sparing techniques, including strictureplasty, can be applied to reduce the risk of short-bowel syndrome.

METHODS

A review of the available literature using the PubMed search engine was undertaken to compile data on the surgical treatment of Crohn's disease.

RESULTS AND CONCLUSION

Data support the use of laparoscopy in treating Crohn's disease, although the potential technical challenges in these settings mandate appropriate prerequisite surgical expertise.

Surgical resection in Crohn's disease: is immunosuppressive medication associated with higher postoperative infection rates?

AIM

The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn's disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

METHOD

With IRB approval, the records of all patients with CD who underwent abdominal surgery between 2001 and 2008 were reviewed for comorbidity, preoperative medication, type of surgery, stoma construction and postoperative complications. Patients were divided into three categories according to the preoperative medication within 90 days of surgery as follows: infliximab (IFX), other drugs including steroids and/or immunosuppressive agents (OD) and no drugs (ND).

RESULTS

Two hundred and twenty-five patients were identified. Preoperative comorbidity, surgical indication and type of surgery were not significantly different among the three groups. Ileocolic resection was the most common procedure [50.8%, IFX group; 61.2%, OD group; 41.3%, ND group (P = 0.09)]. Other procedures included total colectomy (16%), protectomy (15%) and others (18%). Laparoscopic surgery was performed in 47.7%, 45.9% and 29.3% of patients in the IFX, OD and ND groups, respectively (P = 0.04). There were no differences in postoperative rates of infection [pneumonia (P = 0.14), wound infection (P = 0.35), abscess (P = 0.34) or anastomotic leakage (P = 0.44)]. Reoperation was needed in 3.0%, 8.2% and 2.6% of patients in the IFX, OD and ND groups, respectively. Multiple logistic regression found no relationship between infliximab use and infection.

CONCLUSION

There was no difference in the rate of postoperative complications among the groups of patients undergoing surgery for CD pretreated with IFX or other immunosuppressive drugs.

Surgical resection in Crohn's disease: is immunosuppressive medication associated with higher postoperative infection rates?

AIM

The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn's disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

METHOD

With IRB approval, the records of all patients with CD who underwent abdominal surgery between 2001 and 2008 were reviewed for comorbidity, preoperative medication, type of surgery, stoma construction and postoperative complications. Patients were divided into three categories according to the preoperative medication within 90 days of surgery as follows: infliximab (IFX), other drugs including steroids and/or immunosuppressive agents (OD) and no drugs (ND).

RESULTS

Two hundred and twenty-five patients were identified. Preoperative comorbidity, surgical indication and type of surgery were not significantly different among the three groups. Ileocolic resection was the most common procedure [50.8%, IFX group; 61.2%, OD group; 41.3%, ND group (P = 0.09)]. Other procedures included total colectomy (16%), protectomy (15%) and others (18%). Laparoscopic surgery was performed in 47.7%, 45.9% and 29.3% of patients in the IFX, OD and ND groups, respectively (P = 0.04). There were no differences in postoperative rates of infection [pneumonia (P = 0.14), wound infection (P = 0.35), abscess (P = 0.34) or anastomotic leakage (P = 0.44)]. Reoperation was needed in 3.0%, 8.2% and 2.6% of patients in the IFX, OD and ND groups, respectively. Multiple logistic regression found no relationship between infliximab use and infection.

CONCLUSION

There was no difference in the rate of postoperative complications among the groups of patients undergoing surgery for CD pretreated with IFX or other immunosuppressive drugs.

Granulomas in Crohn's disease: does progression through the bowel layers affect presentation or predict recurrence?

AIM

The aim of the study was to correlate the presence and pattern of distribution of granulomas in resected specimens to clinical characteristics and outcome in patients undergoing surgery for Crohn's disease.

METHOD

Patients with Crohn's disease who underwent surgical resection between 2001 and 2007 were identified. Pathology slides were reviewed for the presence, number and location of granulomas in four representative slides from each specimen.

RESULTS

Two-hundred and seven patients were identified. At a mean follow up of 14 months, 39 patients had a recurrence, 22 (57%) of whom underwent reoperation. Ninety-four (45%) patients had granulomas present in the surgical specimen. Patients with granulomas were younger (P<0.001), had a lower preoperative body mass index (P=0.037), were more likely to be female (P=0.017) and were more likely to have extra-intestinal manifestations (P=0.026) or perianal disease (P=0.012). Sites of disease and procedures performed were similar in both groups. Disease recurrence and reoperative rates were similar in both groups, as were length of stay and morbidity rates. The average number of granulomas present in each sampled pathology slide was 7.2, and there was no correlation between number of granulomas and disease severity. No link was found between the depth of involvement of the granulomas and fistulizing or stricturing disease.

CONCLUSION

Granulomas were associated with increased extra-intestinal manifestations and perianal disease, a lower body mass index and younger or female patients. There was no correlation between the presence of granulomas and disease progression or recurrence rates during the short follow-up period of this study.

Idiopathic fistula-in-ano

Fistula-in-ano is the most common form of perineal sepsis. Typically, a fistula includes an internal opening, a track, and an external opening. The external opening might acutely appear following infection and/or an abscess, or more insiduously in a chronic manner. Management includes control of infection, assessment of the fistulous track in relation to the anal sphincter muscle, and finally, definitive treatment of the fistula. Fistulotomy was the most commonly used mode of management, but concerns about post-fistulotomy incontinence prompted the use of sphincter preserving techniques such as advancement flaps, fibrin glue, collagen fistula plug, ligation of the intersphincteric fistula track, and stem cells. Many descriptive and comparative studies have evaluated these different techniques with variable outcomes. The lack of consistent results, level I evidence, or long-term follow-up, as well as the heterogeneity of fistula pathology has prevented a definitive treatment algorithm. This article will review the most commonly available modalities and techniques for managing idiopathic fistula-in-ano.

Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation

BACKGROUND

Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations.

OBJECTIVE

This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation.

DESIGN

Multicenter, prospective observational study.

PATIENTS

Women with symptoms of obstructed defecation.

SETTING

Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela).

INTERVENTIONS

Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans.

MAIN OUTCOME MEASURES

The κ statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele.

RESULTS

Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6-23); median age, 53.4 (range, 26-77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; κ = 0.61; 95% CI = 0.48-0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (κ = 0.79; 95% CI = 0.57-1.0). Intussusception was associated with rectocele in 28 patients for both methods (κ = 0.62; 95% CI = 0.41-0.83). There was substantial agreement for anismus (κ = 0.61; 95% CI = 0.40-0.81) and for rectocele combined with anismus (κ = 0.61; 95% CI = 0.40-0.82). Agreement for grade III enterocele was classified as almost perfect (κ = 0.87; 95% CI = 0.66-1.0).

LIMITATIONS

Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used.

CONCLUSIONS

Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

The differences between American and Chinese patients with Crohn's disease

AIM

The effect of race on Crohn's disease (CD) remains uncertain. This study compared the characteristics of American white patients and Chinese patients with CD.

METHOD

A retrospective chart review was conducted for patients who required management of colorectal CD between 1985 and 2004 at either Cleveland Clinic Florida (CCF) or at the 301 Hospital in China. Data included a family history of CD, smoking history, location of the CD and histopathology.

RESULTS

The mean age of onset in the 153 patients was 29.8 ± 16.4 years for American white patients and 32.4 ± 15.3 years for Chinese patients (not significant). Sixty per cent of American white patients were women vs 37% of Chinese patients (P = 0.003). Twelve per cent of American white patients vs 1% of Chinese patients had a family history of CD (P = 0.016). American white patients had significantly higher rates of arthritis (32%vs 4%), abscess (19%vs 0%), rectal and perineal fistula (52%vs 0%), and disease involving the colon and rectum when compared with Chinese patients (all P < 0.05). American white patients had more colorectal sites involved and higher rates of extraintestinal diseases (40%vs 20%) than Chinese patients (all P < 0.05). Chinese patients had higher rates of ileocaecal disease (82%vs 52%) and deep ulcers (66%vs 24%) in the colorectum (all P < 0.001). There were no statistical differences in the incidence of smoking, perforation, intra-abdominal fistula, stenosis, bowel obstruction, toxic megacolon or granuloma formation.

CONCLUSION

This study found that colorectal CD had a more severe clinical presentation and pathological involvement in American white patients than in Chinese patients.

Energy source instruments for laparoscopic colectomy

BACKGROUND

Colectomy is a common procedures for both benign and malignant conditions. Increasingly more colectomy has been performed laparoscopically and there are several available instruments being used for this procedure. Of which three common dissecting instruments are: monopolar electrocautery scissors (MES), ultrasonic coagulating shears (UCS) and electrothermal bipolar vessel sealers (EBVS). 

OBJECTIVES

The aim is to assess the safety and effectiveness of these instruments.

SEARCH STRATEGY

Studies were identified from PubMed, EMBASE, Cochrane Controlled Trials Register, Cochrane Colorectal Cancer Group Trials Register.  Major journals were specifically hand searched.  All randomised controlled trials were included.

SELECTION CRITERIA

All patients underwent elective laparoscopic or laparoscopic-assisted right, left or total colectomy or anterior resection for either benign or malignant conditions were included in the study.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature searches, assessed the methodological quality of the trials and extracted data. The three primary outcomes were: overall blood loss, complications and operating time.

MAIN RESULTS

Six randomised controlled trials including 446 participants. Two trials compared three types of instruments (MES vs UCS vs EBVS). One trial compared MES and UCS. One trial compared UCS and EBVS. One trial compared 5 mm versus 10 mm EBVS. One trial compared the technique of laparoscopic staplers and clips versus EBVS in pedicle ligation during laparoscopic colectomy. The limitation of this review is the heterogeneity of the trials included. The measured outcomes were covered by one to three studies with small number of participants. With this in mind, there was significant less blood loss in UCS compared to MES. The operating time was significantly shorter with the use of EBVS than MES. No difference between UCS and EBVS apart from EBVS appeared to be handling better than UCS in one study. Haemostatic control was better in UCS and EBVS over MES. No definite conclusion on the cost difference between these three instrument but this would lie in the balance between the instrument cost and the operating time. The handling of 5 mm EBVS was better than 10 mm and its main advantage was trocar flexibility. Laparoscopic staplers/clips used for pedicle ligation in colectomy associated with more failure in vessel ligation and cost more when compared to EBVS.

AUTHORS' CONCLUSIONS

The limitations of this review is the small number of trials and heterogeneity of the studies included. With the current evidence it is not possible to demonstrate which is the best instrument in laparoscopic colectomy. Hopefully more data would follow and subsequent updates of this review could become more informative.

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.

Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients

BACKGROUND

The balance between abdominal and perineal approaches for rectal prolapse is always the higher morbidity but better outcome in the former setting. Therefore, perineal approaches have been preferred for the treatment of full-thickness rectal prolapse (FTRP) in elderly patients. However, laparoscopic rectopexy with or without resection also may be used for elderly patients and may confer the same benefits.

PURPOSE

The objective of this study was to evaluate safety and efficacy of laparoscopic rectopexy compared with perineal rectosigmoidectomy for FTRP in elderly patients.

METHODS

Between July 2000 and June 2009, eight consecutive patients (8 women; mean age, 71 (range, 65-77) years) with FTRP underwent laparoscopic rectopexy (LAP group). During the same period, 143 patients underwent perineal rectosigmoidectomy (PRS group). A total of 123 patients were selected who underwent perineal rectosigmoidectomy (117 women; mean age, 80.7 (range, 66-98) years).

RESULTS

Three patients (37.5%) in the LAP group and 29 patients (23.6%) in the PRS group had undergone previous operations for rectal prolapse. The mean follow-up periods were 6.9 months and 12.8 months, respectively. In the LAP group, operative time was longer (166.5 vs. 73.5 minutes; p > 0.05) and bleeding loss was more (101.7 vs. 31.6; p < 0.05), whereas the length of hospitalization was same between the two groups (5.4 vs. 5.3 days; p > 0.05). Postoperative complications included an incisional hernia in the LAP group (12.5%) and urinary retention (4.8%), anastomotic disruption (2.4%), urinary tract infection (1.6%), and atelectasis (1.6%) in the PRS group (13.8%). Recurrences were 1 (12.5%) in the LAP group and 14 (11.4%) in the PRS group.

CONCLUSIONS

Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with FTRP but results in increased operative time.

Adhesion prevention and reduction: current status and future recommendations of a multinational interdisciplinary consensus conference

Adhesions can be found after virtually every abdominopelvic operation performed through standard laparotomy as well as by laparoscopic approaches. Adhesions can be completely asymptomatic or can cause significant morbidity and mortality including strangulation, obstruction, and necrosis of bowel loops and/or infertility and organ injury during repeat abdominal surgery. Perhaps because of the multifactorial nature of adhesion development, prevention has been very limited. Three anti-adhesion products are commercially available, none of which has been universally accepted as a panacea. Part of the obstacles with adhesion management is the lack of an objective clinically relevant classification to allow their study. Because a single band can cause a life-threatening bowel obstruction, whereas extensive dense intra-abdominal adhesions may be asymptomatic, neither the mere presence or absence of adhesions nor their extent if present is totally adequate endpoints. Adhesions are a major health care burden, and their reduction is a significant unmet need in surgical therapeutics facing all surgeons. Of all the parameters assessing adhesions currently available, the authors believe that adhesion incidence (presence or absence) is the most relevant endpoint with a direct clinical implication. The authors endorse the development of a validated, clinically relevant scale to assess intra-abdominal adhesions. Given the present limitation of objective assessment of adhesions and prediction of their clinical effect, the authors also advocate, when appropriate, the use of one of the Food and Drug Administration-approved adhesion barriers. Further research is required to develop safe and effective anti-adhesion methods as well as better assessment tools for their efficacy.

Laparoscopy for recurrent Crohn's disease: how do the results compare with the results for primary Crohn's disease?

AIM

To assess the feasibility and outcomes of reoperative laparoscopic-assisted surgery for recurrent Crohn's disease compared with index laparoscopic resections.

METHOD

A retrospective analysis of a prospectively maintained database was performed from 2001 to 2008 on patients who had primary laparoscopy (group I) or reoperative laparoscopy for Crohn's disease (group II). Data collection included demographic and surgical data, and postoperative outcomes.

RESULTS

One hundred and thirty patients were included in this study, distributed as follows: group I, 80 patients with a mean age of 35 years; and group II, 50 patients with a mean age of 42 years. Preoperative American Society of Anesthesiologists score and body mass index were similar in both groups. Patients in group II had a longer period of disease (15.5 vs 8.9 years in groups I and II, respectively; P = 0.0002). Immunosuppressive therapy had been utilized in 66 (82.5%) and in 42 (84%) patients in groups I and II, respectively. Ileocolic resection was the most commonly performed procedure in both groups (82%), followed by subtotal colectomy. Conversion rates were 18.7 and 32% in groups I and II, respectively (P = 0.09). The mean operative time (182 vs 201 min) and mean blood loss (161 vs 202 ml) were not significantly different (P > 0.05); however, the overall incisional length was significantly longer in group II (6.7 vs 11.4 cm, P = 0.045). A stoma was created in 17 and 16% of patients in groups I and II, respectively. Overall, early postoperative complications were not statistically significantly different between the two groups (P > 0.05); anastomotic leak occurred in four (5%) and one (2%) patients (P = 0.65), and abdominal abscess in three (3.75%) and four (8%) patients (P = 0.56), in groups I and II, respectively. Reoperative rates were 10 and 6% (P = 0.53), and mean hospital stay was similar in groups I and II respectively (6.7 vs 7.5 days, respectively; P = 0.3266). There was no mortality.

CONCLUSION

The results of laparoscopic-assisted resection for recurrent Crohn's disease are similar to those for primary resection.

The differences between American and Chinese patients with Crohn's disease

AIM

The effect of race on Crohn's disease (CD) remains uncertain. This study compared the characteristics of American white patients and Chinese patients with CD.

METHOD

A retrospective chart review was conducted for patients who required management of colorectal CD between 1985 and 2004 at either Cleveland Clinic Florida (CCF) or at the 301 Hospital in China. Data included a family history of CD, smoking history, location of the CD and histopathology.

RESULTS

The mean age of onset in the 153 patients was 29.8 ± 16.4 years for American white patients and 32.4 ± 15.3 years for Chinese patients (not significant). Sixty per cent of American white patients were women vs 37% of Chinese patients (P = 0.003). Twelve per cent of American white patients vs 1% of Chinese patients had a family history of CD (P = 0.016). American white patients had significantly higher rates of arthritis (32%vs 4%), abscess (19%vs 0%), rectal and perineal fistula (52%vs 0%), and disease involving the colon and rectum when compared with Chinese patients (all P < 0.05). American white patients had more colorectal sites involved and higher rates of extraintestinal diseases (40%vs 20%) than Chinese patients (all P < 0.05). Chinese patients had higher rates of ileocaecal disease (82%vs 52%) and deep ulcers (66%vs 24%) in the colorectum (all P < 0.001). There were no statistical differences in the incidence of smoking, perforation, intra-abdominal fistula, stenosis, bowel obstruction, toxic megacolon or granuloma formation.

CONCLUSION

This study found that colorectal CD had a more severe clinical presentation and pathological involvement in American white patients than in Chinese patients.

Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients?

AIM

The aim of this study was to review the recent results of ileal pouch-anal anastomosis (IPAA) in elderly patients compared with younger patients.

METHOD

Retrospective evaluation was carried out based on a prospective Institutional Review Board approved database of patients who underwent IPAA from 2001 to 2008. Patients aged ≥ 65 years were matched with a group of patients aged < 65 years by gender, date of procedure, diagnosis and type of procedure performed. Preoperative and intra-operative data and early postoperative complications were obtained.

RESULTS

Thirty-three patients (22 women), 32 with mucosal ulcerative colitis, were included in each group. The elderly group had a mean age of 68.7 years, body mass index of 27 kg/m², duration of disease of 17.4 years, high American Society of Anesthesiologists (ASA) score and high incidence of comorbid conditions (87.9% had one or more). Dysplasia and carcinoma were the indication for the surgery in more than 50% of patients, followed by refractory disease (24.4%). The matched younger group had a mean age of 36.9 years, body mass index of 25.4 kg/m², shorter duration of disease (8.1 years; P = 0.001), lower ASA score (P = 0.0001) and lower comorbidity (42.4%; P = 0.0002). Operative data were similar for both groups. The elderly group had a higher rate of rehospitalization for dehydration (P = 0.02). Other medical complications (30 vs 27%) and surgical postoperative complications (33 vs 24%) were similar for both groups. The long-term function and complications were comparable for the groups.

CONCLUSION

Elderly patients who underwent IPAA had more comorbid conditions than younger patients. Except for rehospitalization for dehydration, medical and surgical postoperative complications were not different in the two groups.

Are there predictors of outcome following rectovaginal fistula repair?

BACKGROUND

Rectovaginal fistula is a distressing condition for patients and for physicians who are continuously challenged in providing durable treatment options. The aim of this study is to assess the results of rectovaginal fistula repair and identify predictive factors for poor outcome.

METHODS

Retrospective analysis of patients who underwent rectovaginal fistula repair from 1988 to 2008 was performed. chi tests and logistical regression analysis were used to study treatment outcomes according to the following fistula characteristics: etiology, size, location, and number of prior attempts at fistula repair. In addition, patient factors such as age, body mass index, smoking history, comorbid condition of diabetes, use of steroid and immunosuppressive medications, number of prior vaginal deliveries, and presence of a diverting stoma were analyzed.

RESULTS

A total of 184 procedures were performed in 125 patients. Inflammatory bowel disease was the most common indication for surgery (45.6%), followed by obstetric injury (24%) and surgical trauma (16%). The mean duration of fistula presence was 31.2 months. The procedures performed included endorectal advancement flap (35.3%), gracilis muscle interposition (13.6%), seton placement (13.6%), and transperineal (8.7%) and transvaginal repair (8.1%). The overall success rate per procedure was 60%, with no difference in recurrence rates based on the type of repair. Patients with Crohn's disease had more recurrent fistulas (44.2% success per procedure; P < .01), although 78% eventually healed after an average of 1.8 procedures. Patients with obstetric injuries had an 89% success rate after an average of 1.3 procedures per patient, which is similar to the success rate for traumatic fistulas. Pouch vaginal fistulas had a 91% success rate after an average of 1.6 procedures per patient. The overall success rate per patient was 88% after multiple procedures with a mean follow-up of 16.3 months. Age, body mass index, diabetes, use of steroids and immunosuppressive agents, size and location of the fistula, number of vaginal deliveries, time interval between a recurrent episode and subsequent repair, and the presence of fecal diversion did not affect outcomes. The presence of Crohn's disease and a smoking history are strongly associated with rectovaginal fistula recurrence (P = .02).

CONCLUSIONS

Despite a relatively low initial success rate (60%), most rectovaginal fistulas can be successfully repaired with subsequent operations. Crohn's disease and smoking are associated with adverse outcomes.