Horseshoe abscesses and fistulas: how are we doing?

BACKGROUND

Various surgical treatments exist for horseshoe abscesses and fistulae, including posterior midline sphincterotomy, catheter drainage, cutting and draining setons, and advancement flaps. The aim of this study was to evaluate the long-term results of patients treated for these complex anorectal problems.

METHODS

A retrospective review was undertaken of patients with a diagnosis of horseshoe abscess, horseshoe fistula, postanal space abscess, or postanal space fistula from 1990 to 2001. Long-term follow-up was accomplished by telephone questionnaire.

RESULTS

Thirty-one patients were identified, of whom 17 (54.8%) had a diagnosis of Crohn disease. The diagnosis at presentation included unilateral (ischiorectal) abscess (32.3%), bilateral horseshoe abscess (51.6%), bilateral horseshoe fistula (9.7%), and postanal space abscess (6.4%). Endoanal ultrasonography was used during the preoperative evaluation in 11 patients (35.5%). After referral to our institution, patients underwent a median of four operations (range, 1 to 9). At a mean follow-up of 49.3 months, 60.7% of patients had either healed perineal disease or were asymptomatic with controlled disease. Patients who had a posterior midline sphincterotomy were more likely to be asymptomatic (P=.047). Patients who had a diagnosis of Crohn disease required more operations than those without Crohn disease (3 vs 1.86, P=.02). Only patients who had a diagnosis of Crohn disease had a stoma at their last follow-up (4 of 17, 23.5% vs 0 of 11, 0%; P=.05).

CONCLUSIONS

Patients with horseshoe abscess or fistulae often require multiple operations for treatment but can expect reasonable rates of long-term success in controlling or curing their disease. Those who undergo posterior midline sphincterotomy seem to benefit with higher rates of improved symptoms. Patients with a diagnosis of Crohn disease may fare less well. The role of endoanal ultrasonography in directing therapy remains to be defined.

Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

BACKGROUND

Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.

METHODS

Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.

RESULTS

All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).

CONCLUSIONS

When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons

BACKGROUND

The postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States.

METHODS

A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC.

RESULTS

Only 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice.

CONCLUSIONS

Surveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.

Is the Quality of Life Better in Patients with Colostomy than Patients with Fecal Incontience?

BACKGROUND

A colostomy offers definitive treatment for individuals with fecal incontinence (FI). Patients and physicians remain apprehensive regarding this option because the quality of life (QOL) with a colostomy is presumably worse than living with FI. The aim of this study, therefore, was to compare the QOL of colostomy patients to patients with FI.

METHODS

A cross-sectional postal survey of patients with FI or an end colostomy was undertaken. QOL measures used included the Short Form 36 General Quality of Life Assessment (SF-36) and the Fecal Incontinence Quality of Life score (FIQOL).

RESULTS

The colostomy group included 39 patients and the FI group included 71 patients. The average FI score for FI group was 12 +/- 4.9 (0 = complete continence, 20 = severe incontinence). In the colostomy group the average colostomy function score was 12.9 +/- 3.8 (7 = good function, 35 = poor function). Analysis of the SF-36 revealed higher social function score in the colostomy group compared to the FI group. Analysis of the FIQOL revealed higher scores in the coping, embarrassment, lifestyle scales, and depression scales in the colostomy group compared to the FI group.

CONCLUSION

A colostomy is a viable option for patients who suffer from FI and offers a definitive cure with improved QOL.

Clinical presentation and surgical outcome in patients with solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome is a poorly understood clinical condition, and the schema of treatment has not yet been defined. This study reviewed the clinical spectra and outcome of various surgical treatments in patients with solitary rectal ulcer syndrome. The medical records of all patients with solitary rectal ulcer syndrome between 1992 and 1998 were retrospectively reviewed. Patients in the study population with symptoms and histopathologic findings suggestive of solitary rectal ulcer syndrome were placed in the primary solitary rectal ulcer syndrome group, and patients who underwent surgery for other diseases in whom histopathology confirmed concomitant solitary rectal ulcer syndrome were in the incidental group. Clinical features and outcomes of surgical treatment were documented. Improvement was considered as resolution of presenting symptoms, and non-improvement was considered if presenting symptoms persisted or worsened. The study cohort comprised 49 patients: 20 in the primary group and 29 in the incidental group. Ulcerative morphology was seen predominantly in the primary group (70%); erythematous (45%) and polypoid lesions (34%) were predominant in the incidental group (P = .0025). Clinical improvement after surgery was seen in 74% of patients with primary and 79% with incidental solitary rectal ulcer syndrome (P = NS). Manifestations such as tenesmus and digitation correlated with poorer outcome after surgery in both groups. Solitary rectal ulcer syndrome is a clinical condition associated with functional anorectal evacuatory disorders. The results of this study show the positive role of surgical treatment for underlying functional disorders in the improvement of incidental solitary rectal ulcer syndrome.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

BACKGROUND

Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects.

METHODS

The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure.

RESULTS

A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups.

CONCLUSION

A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

Lengthening of small bowel mesentery: stepladder incision technique

The surgical option of choice in most patients with mucosal ulcerative colitis or familial adenomatous polyposis is restorative proctocolectomy with ileal pouch anal anastomosis. The tension-free anastomosis is one of the most critical steps but may be technically difficult or impossible in some patients because of shortened small bowel mesentery. Various techniques have been described to increase the length of small bowel mesentery. These techniques usually involve selective division of mesenteric blood vessels and meticulous dissection. We describe a new technique of stepladder transverse, transmesenteric incisions in the avascular windows of small bowel mesentery. This provides additional small bowel length without compromising blood supply to the pouch and a simple and safe method of increasing the length of small bowel mesentery. To date, no complications have been reported using this technique.

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease

BACKGROUND

There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD).

METHODS

A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: <or= 3 months, 4-7 months and > 7 months.

RESULTS

From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the <or= 3 month group compared to the other groups. There was no significant difference in the overall incidence of postoperative complications among the 3 groups. Postoperative fistulas were significantly more common after RPC in Groups 1 and 2 as compared to Group 3.

CONCLUSION

Restorative proctocolectomy performed within 3 months after the initial subtotal colectomy was associated with a significant increase in the incidence of intra-operative complications. Although this increase was not statistically significant, there was a significantly higher incidence of fistula formation when RPC was undertaken at up to 7 months after the subtotal colectomy for IBD. Thus, if possible, early RPC after subtotal colectomy should be discouraged.

Effects of radiotherapy on different histopathological types of rectal carcinoma

BACKGROUND

Down staging by pre-operative chemoradiotherapy is currently considered part of the standard therapeutic approach to rectal carcinoma. The aim of this study was to assess the response to chemoradiotherapy of different histopathological types of rectal carcinoma with emphasis on the mucinous variant.

METHOD

Between 1997 and 2002, 71 patients who received pre-operative chemoradiotherapy followed by surgery for rectal carcinoma were enrolled in the study. Staging of the rectal carcinoma was performed according to transrectal ultrasound findings (TN score) prior to the chemoradiotherapy. The chemoradiotherapy was followed by radical resection with mesorectal excision. All surgical specimens were examined by a single pathologist (MB). Pathological TN staging was assessed and tumour regression was graded according to a standard method (TRG1, complete response - TRG5 no response). Tumours were classified as mucinous or nonmucinous according to pre- and post-operative biopsy and specimen histopathological types. TN score change and TRG differences between groups were assessed.

RESULTS

Tumour regression was seen after chemoradiotherapy in 94.4% of the patients, while in 5.6% of the patients no response was found. The change in TN score and TRG were correlated. Higher TRG was associated with a smaller decrease in TN staging. TRG was significantly lower in the nonmucinous compared to the mucinous group and the decrease in TN grade was significantly larger in the nonmucinous group.

CONCLUSION

Mucinous carcinoma was associated with a lower response to pre-operative chemo-radiotherapy in this group of rectal carcinoma patients. Further studies are needed to determine its prognostic value.

Surgical management of pouch-vaginal fistula after restorative proctocolectomy

BACKGROUND

Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF.

METHODS

After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula.

RESULTS

The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision.

CONCLUSIONS

Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Anatomic extent of colitis and disease severity are not predictors of pouchitis after restorative proctocolectomy for mucosal ulcerative colitis

BACKGROUND

Pouchitis is a common complication following restorative proctocolectomy with ileal pouch anal anastomosis (RPC-IPAA) for mucosal ulcerative colitis (MUC). The aim of this study was to determine if perioperative anatomic extent and severity of disease are predictors of pouchitis.

METHODS

All consecutive patients who underwent RPC-IPAA for MUC between 1988 and 2002 were retrospectively studied. Pouchitis was classified as acute, recurrent or refractory. Colectomy specimen slides were histopathologically evaluated by a single blinded pathologist (MB), who assessed extent and severity of disease.

RESULTS

Of 112 patients assessed, 70 (62.5%) had some form of pouchitis at a median follow-up of 38 months (range, 1-204 months). No association was found between the extent or severity of disease and subsequent development of acute or chronic pouchitis. A positive correlation was found between the histopathologic score and the occurrence of clinical pouchitis (p=0.014). The presence of colonic metaplasia in the pouch biopsy was significantly correlated with a histopathologic diagnosis of pouchitis (p<0.0001, r=-0.449).

CONCLUSIONS

Following RPC for MUC, the extent and severity of disease do not predict the subsequent development of pouchitis.

Biofeedback therapy for rectal intussusception

BACKGROUND

Surgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception.

METHODS

We retrospectively evaluated the results of electromyography (EMG)-based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder.

RESULTS

A total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean+/-SD) was 2.0+/-6.8 before and 4.1+/-4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8+/-3.5 before to 1.5+/-2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty-three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were constipated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0+/-0.7 before to 0.07+/-0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1+/-4.2 before to 4.6+/-3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group.

CONCLUSIONS

Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study

BACKGROUND

Narcotics are routinely used to decrease postoperative pain after laparotomy. But they are associated with unwarranted side effects. The aim of this study was to assess the effectiveness of local perfusion of bupivacaine in decreasing narcotic consumption after midline laparotomy.

STUDY DESIGN

We performed a prospective, randomized, double blind study involving patients who underwent a midline laparotomy with subsequent wound closure. Patients were randomized to receive a 72-hour continuous wound perfusion through the ON-Q pain management system (I Flow Corporation) of the local anesthetic bupivacaine (0.5%, study group) or 0.9% NaCl (control group). In addition, all patients received standardized intraoperative analgesia and postoperative morphine patient-controlled analgesia. Total postoperative analgesic requirement, pain control, recovery of bowel function, and complications were recorded.

RESULTS

Seventy patients were recruited: 35 in the study group (mean age, 55.7 years) and 35 in the control group (mean age, 58.8 years). There was no difference in overall postoperative pain scores. Patients in the study group reported earlier ambulation as compared with the control group. Mean (+/-SD) daily narcotic requirements were significantly less in the study group versus the control group (33.7+/-32 mg versus 60.1+/-62 mg, respectively; p=0.03). Patients in the study group made 50% fewer attempts to receive patient-controlled analgesia (p=0.011). But there was no significant difference in length of hospitalization or time to first bowel movement.

CONCLUSIONS

This preliminary pilot study revealed that the ON-Q pain management system after midline laparotomy, as part of a multimodal approach, is an effective approach to postoperative pain control.

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians

OBJECTIVE

Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA.

METHODS

After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years.

RESULTS

From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2).

CONCLUSION

IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.

Small bowel transit does not correlate with outcome of surgery in patients with colonic inertia

Colonic inertia is a motility disorder that may involve dysfunction of the entire intestinal tract. The aim of this study was to assess whether small bowel transit time is associated with the outcome of total abdominal colectomy in patients with colonic inertia. A retrospective review of the medical records of patients who underwent total abdominal colectomy for colonic inertia was performed to identify those individuals who had a preoperative small bowel transit study. The outcome of surgery was correlated with the results of the small bowel transit study. Fifty-two female patients underwent total abdominal colectomy for colonic inertia between 1988 and 2000, of whom 17 (33%) had a preoperative small bowel transit study. The small bowel transit time was normal in 11 patients (65%), and the time was abnormally prolonged in 6 (35%). At a mean follow-up of 37 months, there was no significant difference in the outcome of surgery between the two groups. A good result was achieved in 36% of the normal small bowel transit time group compared with 33% in the abnormal group; the result was fair in 63% and 33%, and poor in 0% and 33%, respectively (P=NS). The small bowel transit study does not reliably predict the outcome of total abdominal colectomy in patients with colonic inertia.

The efficacy of a nerve stimulator (Cavermap) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision

PURPOSE

Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed.

PATIENTS AND METHODS

Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. CaverMap was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeon's ability to localize the nerves and CaverMap to confirm this were evaluated.

RESULTS

Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. CaverMap successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. CaverMap improved the identification rate in four of the remaining five patients. After proctectomy, CaverMap successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device.

CONCLUSION

CaverMap may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation.

Quality of life after colectomy for colonic inertia

BACKGROUND

Total abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long-term health related quality of life in these patients in relation to their functional outcome.

METHODS

A consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was health-related quality of life assessed at follow-up using the SF-36 Health Survey.

RESULTS

A total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3+/-27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7+/-2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF-36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations.

CONCLUSIONS

After TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

Assessment of long-term quality of life after laparoscopic and open surgery for Crohn's disease

OBJECTIVE

Surgery for Crohn's disease (CD) is associated with a high recurrence rate and quality of life (QOL) in these patients is controversial. The aim of this study was to assess QOL in patients after laparoscopic and open surgery for CD by two different validated instruments, a generic nonspecific score and a specific gastrointestinal QOL index.

PATIENTS AND METHODS

Patients with CD who underwent elective laparoscopic or open ileocaecal resection with primary anastomosis between 1992 and 2000 were followed for recurrence and surgery-related complications. QOL was assessed by the SF-36 Health Survey containing a mental (MCS) and a physical (PCS) component summary score and by the Gastrointestinal Quality of Life Index (GIQLI) developed by Eypasch.

RESULTS

Thirty-seven patients with a mean age of 48.8 +/- 18.4 years including 23 females and 14 males were evaluated at a mean follow-up of 42.6 +/-25.8 months (minimum of 8 months). Twenty-one (57%) patients underwent laparoscopic resection and 16 (43%) open surgery. Both groups were well matched for age, gender, ASA class and body mass index. Fourteen (38%) patients developed recurrent disease and 3 (8%) had postoperative incisional hernias. Overall, QOL scores were 103 +/- 26.8 for the GIQLI, 47.2 +/- 11.8 for the PCS, and 49.2 +/- 11.5 for the MCS. The GIQLI correlated well with the SF36, correlation coefficient = 0.68 for GIQLI vs PCS (95% CI, 0.41,0.95) and 0.67 for GIQLI vs MCS (95%CI, 0.39, 0.95), respectively. When compared to the general US population, mean GIQLI scores (-13.8, P = 0.002) and mean PCS scores (-4.7, P = 0.001) were significantly lower in these patients than in healthy individuals. In a multivariate analysis of impact factors on QOL, recurrence within the follow-up period was the single significant determinant reducing the PCS (-35.1, P = 0.026) and the GIQLI (-36.1, P = 0.018).

CONCLUSION

QOL is significantly reduced in patients with CD at long-term follow-up after both laparoscopic and open surgery. Recurrence is the only factor adversely affecting QOL of CD patients in remission irrespective of the operative technique applied.

Not all inflammation in the right lower quadrant is appendicitis: a case report of Escherichia coli O157:H7 with a review of the literature

Although significant work has been presented on this subject in pediatric, infectious disease, and epidemiologic literature, there is a noteworthy lack of information on Escherichia coli O157:H7 in any surgical journals. As this disease can present with signs and symptoms often ascribed to the acute abdomen, it is imperative that the general surgeon, pediatric surgeon, and colorectal surgeon are all familiar with this infection and its clinical ramifications. A case report followed by a review of the literature is presented.

Recurrence rates at minimum five-year follow-up: laparoscopic versus open sigmoid resection for uncomplicated diverticulitis

The aim of the study was to compare the impact of surgical access to sigmoid resection on recurrence rates in patients with uncomplicated diverticulitis of the sigmoid (UDS) at a minimum follow-up of five years. Recurrence after surgery was defined as left lower quadrant pain, fever and leucocytosis with consistent CT and enema findings on admission and at 6 weeks, respectively. Outcome measures included splenic flexure mobilization, specimen length, inflammation at proximal resection margin and presence of teniae coli at distal resection margin. Seventy-nine patients undergoing laparoscopic sigmoid resection (LSR) were compared with 79 matched controls with open sigmoid resection (OSR) operated on at two institutions during the same period. Patients were well matched for age, gender, body mass index, ASA grading and symptoms duration, but not for follow-up length (81.9 vs. 86.9 months, p = 0.046). The rate of splenic flexure mobilization (19 vs. 41, p 0.001), specimen length (16.1 vs. 18.3 cm, p = 0.048), presence of inflammation at proximal resection margin (21 vs. 4, p 0.001), and presence of teniae coli at distal resection margin (4 vs. 53, p 0.001). Three LSR patients and 7 OSR patients had one recurrence (p = 0.19). There were no significant differences in rates of flexure mobilization, specimen length, and rates of inflammation present at proximal resection margin in 10 recurring and 145 non-recurring patients. The rate of teniae coli present at distal resection margin was significantly increased in recurring patients (7 vs. 43, p = 0.03). Surgical access to sigmoid resection for UDS is unlikely to have an impact on recurrence rates provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid.

The efficacy of a nerve stimulator (CaverMap) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision

PURPOSE

Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed.

PATIENTS AND METHODS

Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. CaverMap was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeon's ability to localize the nerves and CaverMap to confirm this were evaluated.

RESULTS

Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. CaverMap successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. CaverMap improved the identification rate in four of the remaining five patients. After proctectomy, CaverMap successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device.

CONCLUSION

CaverMap may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation.

Abnormality of peptide YY and pancreatic polypeptide immunoreactive cells in colonic mucosa of patients with colonic inertia

The etiopathology of colonic inertia remains unclear. Current studies show that pancreatic polypeptide-fold family members can serve as regulators of colonic motility and transit. Thus, the cells containing these peptides on colonic mucosa could be abnormal in patients with colonic inertia. We aimed to evaluate the immunocytochemical staining of peptide YY (PYY) and pancreatic polypeptide (PP) immunoreactive cells, and detect if alteration of these cells relates to an increase in enterochromaffin cells (EC) demonstrated by chromogranin A (CgA), in the colonic mucosa of patients with colonic inertia. Nineteen consecutive patients (18 female, 1 male; age, 43.7+/-11.5 years) who underwent subtotal colectomy for colonic inertia were assessed. The control group consisted of 15 patients (all female; age, 50.7+/-12.5 years) who underwent colonoscopic biopsies from the right and left colon for indications other than constipation, inflammatory bowel diseases, diarrhea, or neoplasm. Hollande's-fixed, paraffin-embedded tissues of both right and left colons were collected. Immunocytochemical staining of PYY, PP, or CgA was performed on 4-microm tissue sections with the respective primary rabbit antibody, the biotinylated secondary antibody, and enzyme-labeled streptavidin. The average number of positive cells per microscopic field (200x) was calculated. Positive cells were classified as strongly, moderately, and weakly staining. The proportion of the variously stained cells is expressed as the percentage of the entire positive cell population. On both sides of the colon, the percentages of strongly and moderately stained PYY positive cells were higher in the patient group compared to the controls (right side, 10.6 and 27.3 vs. 6.1 and 18.7%, respectively; left side, 9.4 and 23.9 vs. 6.2 and 23.1%, respectively) (P < 0.01). Furthermore, in the patients with colonic inertia, the percentages of strongly and moderately stained PYY-positive cells were higher in the right-side colon than in the left (P < 0.01). There was no difference in the number of PYY-positive cells between the patients and the controls. PP-positive cells were very rare in all specimens and were found in 7 of 19 cases (36.84%) in the right-side colon and 16 of 19 (84.21%) in the left-side colon in the patient group (P < 0.01, left vs. right). In contrast, the number of EC in the left colon of patients (16.8+/-10.2) was significantly higher than that in the right side (9.4+/-6.0) (P < 0.01) or that in the left side in the control group (10.4+/-6.0) (P < 0.05). We conclude that in the colonic mucosa of patients with colonic inertia, PYY-positive cells present with higher immunoreactivity, indicating that they may contain more hormones, especially on the right side of the colon. However, the PPY- and PP-positive cells did not relate to the increased EC. and It is therefore suggested that the altered PYY in the colonic mucosa may partially contribute to the etiopathology of colonic inertia.

Does rectal wall tumor eradication with preoperative chemoradiation permit a change in the operative strategy?

PURPOSE

Preoperative chemoradiation may downstage locally advanced rectal cancer and, in some cases, with no residual tumor. The management of complete response is controversial and recent data suggest that radical surgery may be avoided in selected cases. Transanal excision of the scar may determine the rectal wall response to chemoradiation. This study was designed to assess whether the absence of tumor in the bowel wall corresponds to the absence of tumor in the mesorectum, known as true complete response.

METHODS

A retrospective review of the medical records of patients who underwent preoperative chemoradiation for advanced mid (6-11 cm from the anal verge) and low (from the dentate line to 5 cm from the anal verge) rectal cancer (uT2-uT3) followed by radical surgery with total mesorectal excision was undertaken. Patients in whom the pathology specimen showed no residual tumor in the rectal wall (yT0, "y" signifies pathologic staging in postradiation patients) were assessed for tumoral involvement of the mesorectum.

RESULTS

A total of 109 patients underwent preoperative, high-dose radiation therapy (94 percent with 5-fluorouracil chemosensitization), followed by radical surgery for advanced rectal cancer. Preoperatively, 47 patients were clinically assessed to have potentially complete response. After radical rectal resection, pathology did not reveal any residual tumor within the rectal wall (yT0) in 17 patients. In two (12 percent) of these patients, the mesorectum was found to be positive for malignancy: one had positive lymph nodes that harbored cancer; one had tumor deposits in the mesorectal tissue.

CONCLUSIONS

Compete rectal wall tumor eradication does not necessarily imply complete response, because the mesorectum may harbor tumor cells. Thus, caution should be exercised when considering the avoidance of radical surgery. Reliable imaging methods and clinical predictors for favorable outcome are important to allow less radical approaches in the future.

Topical tacrolimus (FK506) in the treatment of recalcitrant parastomal pyoderma gangrenosum associated with Crohn's disease: report of two cases

INTRODUCTION

Pyoderma gangrenosum is a rare idiopathic skin disorder associated with other diseases, including inflammatory bowel disease. The commonest site is the skin, but sometimes it can occur in the parastomal region. Most of these cases respond to treatment with systemic corticosteroids and cyclosporin or local Kenalog injections.

METHODS

The following are two cases of parastomal pyoderma in patients not responding to the standard measures. These patients were treated with topical tacrolimus.

RESULTS

These patients showed dramatic improvement in one week with complete resolution and re-epithelialization of skin within two weeks.

CONCLUSION

Pyoderma gangrenosum is a difficult problem to manage and its early resolution is important. In these two reported cases, the improvement was dramatic, therefore topical tacrolimus should be considered early in the management.