Endorectal advancement flap in perianal Crohn's disease

The aim of this study was to evaluate the outcome of patients undergoing endorectal advancement flap repair for perianal Crohn's disease relative to the primary site of intestinal Crohn's disease. From January 1991 to December 1995, 31 consecutive endorectal advancement flap repairs were performed in 26 patients. The results relative to surgical outcomes, length of hospitalization, and recurrence were analyzed. The mean patient age was 40.2 years (range, 16-70). Type of fistulas included: rectovaginal: 20 (64.5%), fistula in ano: 8 (25.8%), rectourethral: 1 (3.2%) and others: 2 (6.5%). The mean length of follow-up was 17.3 (range 3-60) months. The mean length of hospitalization was 3.7 (range 2-5) days. A temporary diverting stoma was created in 6 patients with a 66.7% (4/6) surgical success rate. Twenty-one of the 26 patients had previous procedures consisting of 12 (38.7%) bowel resections, 6 (19.4%) seton placements, 4 (12.9%) drainages, and 6 (19.4%) diverting ileostomies. Eleven patients had multiple procedures. Ultimately, fistulas were eradicated in 22 (71%) cases, including 15 (75%) of the 20 with rectovaginal fistulas and 7 (63.6%) of the 11 with other fistulas. There was no mortality; morbidity included a flap retraction in 1 patient, who required antibiotics for 5 days and bleeding in 1 patient, who required reoperation. Success was noted in 2 of 8 (25%) patients with small bowel Crohn's disease as compared to 20 of 23 (87%) patients without small bowel Crohn's disease (P < 0.05). Endorectal advancement flap is an effective surgical modality for the treatment of fistulas due to perianal Crohn's disease but is less apt to succeed in patients with concomitant small bowel Crohn's disease.

Laparoscopic abdominoperineal resection for anorectal cancer

The use of the laparoscopic technique in treating colorectal malignancies for cure is still a controversial issue. The aim of this study was to evaluate the outcome of laparoscopic abdominoperineal resection (APR) in treating malignancies of the lower rectum and anus and to compare the results with patients of matched age and diagnosis treated by conventional open APR by the same surgeon during the same time period. Between August 1991 and December 1996, we performed 235 laparoscopic colorectal procedures, including 8 laparoscopic APRs for malignancies of the lower rectum or anus. There were 6 female and 2 male patients of a mean age of 67 years. Pathologies included 4 adenocarcinomas, 2 melanomas, 1 leiomyosarcoma, and 1 squamous cell carcinoma. Four procedures were laparoscopically completed, and 3 were laparoscopic-assisted. One was converted to an open procedure due to dense adhesions. Five procedures were performed with palliative intent, whereas 3 were performed with curative intent. These patients were evaluated for procedural safety, distal and lateral resection margins, number of lymph nodes harvested, operative time, postoperative ileus, length of hospital stay, morbidity, and mortality. Results were compared with 7 conventional APRs performed between 1991 and 1996, 5 of which were performed for palliation. Histologic studies of the specimen demonstrated free lateral resection margins in all cases in both groups. No differences were noted in the mean free distal resection margins among the four groups: laparoscopic, 2.5 cm; laparoscopic-assisted, 3 cm; converted, 6 cm; and open, 3.6 cm. Mean lymph node harvest was 9, 9, 9, and 10 nodes, respectively. Mean length of surgery was 181, 198, 240, and 131 minutes, respectively. The length of postoperative ileus was 3.2, 7, 3, and 5.9 days, respectively. Mean postoperative length of stay was 6.5, 7, 6, and 12.5 days, respectively. Morbidity was 25 per cent in the laparoscopy group and 43 per cent in the open group. There was no 30-day postoperative mortality recorded in any group. Laparoscopic APR is associated with a 50 per cent reduction in the length of hospitalization without any compromise to lateral or distal resection margins, number of lymph nodes harvested, or morbidity.

Comparison of three perineal procedures for the treatment of rectal prolapse

BACKGROUND

The optimal surgical procedure for the management of rectal prolapse is still under debate. Therefore, the aim of this study was to compare the short-term outcome of three perineal procedures in patients with rectal prolapse.

METHODS

Between April 1989 and April 1995, all consecutive patients who had Delorme's procedure, perineal rectosigmoidectomy, or perineal rectosigmoidectomy with levatoroplasty for full-thickness rectal prolapse were clinically and physiologically assessed before and after surgery. A standard incontinence scoring system, based on the frequency and type of incontinence (0 = full continence, 20 = complete incontinence), was used to compare the results of each procedure. Additionally, morbidity and mortality and clinical and functional outcome were evaluated and compared.

RESULTS

The study group of 61 patients who had perineal procedures for rectal prolapse included 55 women and 6 men, with a mean age of 75 years (range, 48 years to 101 years); 16 patients died of comorbid conditions between 3 months and 42 months after surgery. There were statistically significant differences among the groups relative to short-term recurrence rates, postoperative incontinence scores, mean resection length, coloanal anastomotic stricture, and leak. However, preoperative and postoperative anal manometry did not reveal statistically significant changes within or between the groups.

CONCLUSIONS

Perineal rectosigmodectomy with levatoroplasty has the best short-term outcome for the treatment of rectal prolapse.

Should ileoanal pouch surgery be denied to patients with low resting pressures?

Our aim was to evaluate any impact of preoperative resting pressure upon postoperative physiological results in patients undergoing ileal pouch anal anastomosis. Ninety patients who had undergone manometric study before and 1 year after surgery were divided into two groups determined by a preoperative mean resting pressure of > 50 mm Hg or < or = 50 mm Hg. There were significant differences between these two groups concerning preoperative maximum resting pressure (P < 0.001) and length of the high-pressure zone (P < 0.005). However, such a trend was not seen postoperatively. There were no differences between these two groups relative to postoperative mean or maximum resting pressure, maximum squeeze pressure, length of high-pressure zone, sensory threshold, or capacity. The mean resting pressure decreased after pouch surgery in 82 per cent of patients with a preoperative mean resting pressure of > 50 mm Hg. Conversely, 83 per cent of patients with a preoperative mean resting pressure of < or = 50 mm Hg experienced an increase in mean resting pressure after pouch surgery. Only 4 of 23 patients with a preoperative mean resting pressure of < or = 50 mm Hg had decreased postoperative mean resting pressure. This latter finding has not been previously described. However, the mean resting pressure of those four patients more than fully recovered within 2 to 3 years after surgery. Although preoperative manometry may be useful to analyze data and to counsel patients, it should not be used to deny patients surgery. Moreover, this study has revealed that patients with lower resting pressures do not suffer a deleterious decrease in resting pressure but actually have improved postoperative mean resting pressure.

Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions

AIM

The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery.

METHODS

All eligible patients were prospectively randomized to receive either 4 l of standard polyethylene glycol (PEG) solution or 90 ml of sodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxon's rank-sum test and Fisher's exact test.

RESULTS

Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaP solutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P < 0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17 vs. 32 percent; P < 0.0002), less abdominal pain (12 vs. 22 percent; P = 0.004), less bloating (7 vs. 28 percent), and less fatigue (8 vs. 17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P < 0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P < 0.0001). For quality of cleansing, surgeons scored NaP as "excellent" or "good" in 87 compared with 76 percent after PEG (P = not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P = not significant).

CONCLUSION

Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions

AIM

The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery.

METHODS

All eligible patients were prospectively randomized to receive either 4 l of standard polyethylene glycol (PEG) solution or 90 ml of sodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxon's rank-sum test and Fisher's exact test.

RESULTS

Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaP solutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P < 0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17 vs. 32 percent; P < 0.0002), less abdominal pain (12 vs. 22 percent; P = 0.004), less bloating (7 vs. 28 percent), and less fatigue (8 vs. 17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P < 0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P < 0.0001). For quality of cleansing, surgeons scored NaP as "excellent" or "good" in 87 compared with 76 percent after PEG (P = not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P = not significant).

CONCLUSION

Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Management of obliterating stricture after coloanal anastomosis

We present an unconventional approach to the management of a severe stricture with complete luminal obliteration after a coloanal anastomosis which was protected with a diverting loop ileostomy. The colonoscope was inserted in an antegrade fashion into the defunctionalized limb of the loop ileostomy and advanced to the level of the stricture. Under colonoscopic vision, a Kelly clamp was carefully introduced transanally through the stricture into the proximal lumen. The strictured anastomosis was then dilated with calibrated Hegar dilators. Periodic dilatations followed by closure of the ileostomy completed the management. The technique obviated the need for a more extensive surgical procedure.

Laparoscopic colorectal surgery. Do we get faster?

BACKGROUND

A variety of parameters can affect the outcome of laparoscopic colorectal surgery. All consecutive laparoscopic colorectal procedures (LCP) were analyzed in an attempt to define an operative time curve for different categories of procedures. Additionally, impacts of case number and procedure type on length of procedure were assessed.

METHODS

Our computerized data system was reviewed for all patients who underwent LCP in a 4-year period. Parameters reviewed included age, sex, surgical indications, procedures performed, length of procedure, intraoperative and postoperative complications, incidence and causes for conversion, duration of postoperative ileus, and hospital stay.

RESULTS

Between August 1991 and December 1995, 175 patients with a mean age of 48.4 (range 15-88) years underwent LCP. Patients were divided chronologically into five consecutive groups. Procedures were classified as either basic or complex. Complex procedures were those in which there was either a fixed tumor, an abscess or fistula, or extensive intraabdominal adhesions from prior surgery. Complex procedures performed each year ranged from 37% to 66%. As well, the percentage of patients with adhesions increased from 17% in 1991 to 29% in 1995. Despite increased difficulty, the intraoperative complication rate fell significantly from 29% in 1991 to 8% in 1995 (p < 0.005). Additionally, the operative length decreased from a mean of 201 min in 1991 to a mean of 141 min in 1995 (p < 0.05).

CONCLUSION

The rapid improvement in these parameters may reflect both ascents in the learning curve and change in type of procedure. Adhesions, due to prior surgery or inflammation making dissection tedious, is the most important technical factor which effects operation time (p < 0.001). However, despite increased complexity, operating time decreased, reflecting improved skills. Thus, the experienced laparoscopic surgeon can increase the spectrum of applications with expectations of shorter operations and lower complication rates.

Laparoscopic surgery for diverticulitis

BACKGROUND

Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach.

METHODS

From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p = NS).

RESULTS

Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05).

CONCLUSION

In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment.

Results of perineal procedures for the treatment of rectal prolapse

The optimal surgical procedure for the management of rectal prolapse is still under debate. Therefore, the aim of this study was to evaluate the short-term outcome of perineal procedures in patients with rectal prolapse. Between April 1989 and April 1995, all consecutive patients at the Cleveland Clinic Florida who underwent Delorme's procedure or perineal rectosigmoidectomy with or without levatoroplasty for full-thickness rectal prolapse were evaluated. Clinical and physiological assessments were performed before and after surgery. A standard continence scoring system, based on the frequency and type of incontinence (0 = full continence, 20 = complete incontinence) was used to assess the results of each procedure. Additionally, morbidity and mortality, and clinical and functional outcomes were evaluated. Sixty-one patients underwent perineal procedures for rectal prolapse; 16 patients died from comorbid conditions after undergoing postoperative physiologic assessment. These 55 females and 6 males, with a mean age of 75 (range, 48-101) years were studied. Patients were followed up for 27.2 (6-72) months, and mean prolapse duration was 4.2 (0.2-30) years. Although mean preoperative incontinence score was 15.9 (8-20), it was 6.3 (range, 0-12) in postoperative course. Mean resection length of rectosigmoid was 23.3 (3-71) cm, and in these patients, two (3.3%) coloanal anastomotic leaks and four (6.5%) anastomotic strictures were observed. There was one postoperative death. There were statistically significant differences among the groups relative to short-term recurrence rates, postoperative incontinence scores, mean resection length, coloanal anastomotic stricture, and leak (P< 0.001). However, pre- and postoperative anal manometry did not reveal statistically significant changes (P > 0.05) in each group or among the groups. Perineal procedures were found to be safe and effective in eradicating rectal prolapse and improving fecal incontinence in the elderly.

Initial North American experience with botulinum toxin type A for treatment of anismus

PURPOSE

Botulinum toxin type A (BTX-A), produced by Clostridium botulinum, is a potent neurotoxin. The purpose of this study was to evaluate the efficacy of BTX-A for treatment of anismus.

MATERIALS AND METHODS

All patients treated with BTX-A for anismus were evaluated. Eligibility criteria included a history of chronic assisted evacuation (laxatives, enemas, or suppositories), demonstration of anismus by cinedefecogram and electromyography, and failure of a minimum of three sessions of supervised biofeedback therapy (BF). Contingent on body mass, 6 to 15 units of BTX-A was injected bilaterally under electromyography guidance into the external sphincter or the puborectalis muscle. Treatment was repeated as necessary for a maximum of three sessions during a three-month period. Success was considered as discontinuation of evacuatory assistance and was evaluated between one and three months and again at up to one year.

RESULTS

Between July 1994 and May 1995, four patients ranging from 29 to 82 years in age (2 females, 2 males) had anismus that failed to respond to between 3 and 15 biofeedback sessions. All patients improved between one and three months after BTX-A injection, and two had sustained improvement for a range of three months to one year. There was no morbidity or mortality associated with BTX-A injection.

CONCLUSIONS

BTX-A is extremely successful for temporary treatment of anismus that is refractory to BF management. However, because the mechanism of action is short, longer term results are only 50 percent successful. Hopefully, modifications in the strain of BTX-A and dose administered will allow longer periods of success or a repeat trial of BF. Nonetheless, this preliminary report is very encouraging in offering a method of managing this recalcitrant condition.

Serum electrolyte abnormalities secondary to Fleet's Phospho-Soda colonoscopy prep. A review of three cases

The authors report three cases of adverse reactions to commonly used lavage solutions generally believed harmless.

Stimulated gracilis neosphincter operation. Initial experience, pitfalls, and complications

PURPOSE

The stimulated gracilis neosphincter is accepted as a viable option in select patients with fecal incontinence. The aim of this study was to review the initial problems and complications.

METHODS

A prospective analysis of all patients who underwent this procedure was undertaken. Stage I consisted of the distal vascular delay of the muscle and creation of a temporary stoma. Stage II was the transposition of the muscle and implantation of the stimulator and electrodes. Low frequency electrical stimulation was applied to the muscle for 12 weeks, after which Stage III (stoma closure) was undertaken.

RESULTS

From March 1993 to December 1995, 17 patients (9 females and 8 males) with a mean age of 42.2 (range, 19-72) years underwent the procedure. One patient died from pancreatitis and another from small-bowel adenocarcinoma, three and six months after the procedure, respectively. Two patients (one with Crohn's disease) required permanent stomas. One additional patient required a permanent stoma because of lead fibrosis. Other complications noted during ascent of the learning curve included seroma of the thigh incision, excoriation of the skin above the stimulator, fecal impaction, anal fissure, parastomal hernia, rotation of the stimulator, premature battery discharge, fracture of the lead, perineal skin irritation, perineal sepsis, rupture of the tendon, tendon erosion, muscle fatigue during programming sessions, and electrode displacement from the nerve or fibrosis around the nerve. However, ultimately after rectification of these problems, 13 of the 15 eligible patients had stoma reversal. Manometric results showed an average basal pressure of 43 mmHg and an average maximum squeeze pressure that increased from 36 mmHg before surgery to 145 mmHg by stimulation (P < 0.01). Based on objective functional questionnaires, 9 of 15 (60 percent) evaluable patients reported improvement in continence, social interactions, and quality of life. Three of these nine patients require daily use of enemas.

CONCLUSION

Although the stimulated gracilis operation is a feasible procedure for selected patients with severe incontinence, the learning curve is steep. Although the ultimate outcome in a selected group of patients can be very gratifying, major technical modifications are required before use beyond a research protocol setting. Furthermore, patients must have the psychological strength, emotional commitment, and financial resources that may be necessary for multiple revisional surgeries or ultimate device failure.

Is complete laparoscopic colectomy superior to laparoscopic assisted colectomy?

Much debate has centered around what constitutes a true laparoscopic colon resection. Purists argue that intracorporeal division of the mesentery and anastomosis confer a benefit over a "laparoscopic assisted" procedure. The aim of this study was to further examine this issue. Data were prospectively collected on 102 consecutive laparoscopic colon resections. Five procedures were converted to open cases and were excluded from analysis. Procedures were divided into two groups. Group 1 (n = 34) consisted of complete laparoscopic procedures (no abdominal incision was made): abdominoperineal resection (3), Hartmann's reversal (3), end colostomy (7), low anterior resection (5), proctectomy (1), sigmoid colectomy (15). Group 2 (n = 63) consisted of laparoscopic "assisted" procedures (i.e., an incision was made to facilitate anastomosis, division of the mesentery, and/or specimen retrieval): Ileocolic resection (6), restorative proctocolectomy (26), right colectomy (19), subtotal colectomy/end ileostomy (5), subtotal colectomy/ileorectal anastomosis (7). Length of hospitalization and duration of postoperative ileus were compared. A subset analysis of right colectomy (intracorporeal mobilization and extracorporeal division of the mesentery and anastomosis) versus sigmoid colectomy (intracorporeal mobilization, division of the mesentery and anastomosis) was also performed. There were no statistically significant differences in length of hospital stay (Group 1, 7.47 +/- 2.75 days; Group 2, 7.78 +/- 5.55 days) or duration of postoperative ileus (Group 1, 3.24 +/- 1.56 days; Group 2, 3.68 +/- 1.58 days). Similarly, in the sigmoid colectomy versus right colectomy subset analysis, there were no statistically significant differences in length of hospital stay (sigmoid colectomy, 7.92 +/- 2.90 days; right colectomy, 6.40 +/- 1.50 days) or duration of postoperative ileus (sigmoid colectomy, 3.36 +/- 1.39 days; right colectomy, 3.18 +/- 1.07 days). Our data demonstrate that intracorporeal division of the mesentery and anastomosis confer no advantage over the laparoscopic assisted procedures. Data were prospectively collected on 102 consecutive laparoscopic colon resections. There were no statistically significant differences in length of hospital stay or duration of postoperative ileus regardless of whether intracorporeal or extracorporeal mesenteric division and anastomosis were undertaken. These data demonstrate that a completely laparoscopic procedure does not appear to offer any advantage as compared to a laparoscopic assisted one.

[Anorectal diseases in patients with human immunodeficiency virus (HIV) infection]

BACKGROUND

The incidence of VIH-related disease has arisen dramatically in the last decade. Many of these patients will present with specific anorectal complaints.

PURPOSE

This review paper was performed to discuss the diagnostic and therapeutic implications of anorectal diseases in patients with VIH infection.

RESULTS

A detailed sexual history is important in order to document the mode of transmission. The nature of the anorectal complaint is then evaluated and classified as infectious, neoplastic or idiopathic. Treatment should be planned accordingly.

CONCLUSIONS

In the 1990's it's important that the physician who cares for patients with anorectal complaints be familiar with VIH-related diseases and their treatment plans.

Functional outcome of the double stapled ileoanal reservoir in patients more than 60 years of age

Total proctocolectomy with creation of an ileoanal reservoir (IAR) is currently the preferred surgical treatment of mucosal ulcerative colitis and familial adenomatous polyposis. However, the creation of an IAR on older patients is controversial and commonly avoided because of anticipated poor functional results and increased morbidity. We prospectively studied 140 consecutive patients who underwent a double stapled IAR (DSIAR) between 1988 and 1993. We compared the outcome of 14 patients (Group I) 60 years of age or older (mean 65, range 60-71 years; 10 males and 14 females), to 126 patients (Group II) under the age of 60 (mean 37, range 12-59 years; 80 males and 14 females). Mucosal ulcerative colitis and indeterminate colitis were noted, respectively, in 12 (93%) and 1 (7%) patients in Group I and in 94 (75%) and 5 (4%) patients in Group II. In Group II, 21 (16%) patients had familial adenomatous polyposis, and 6 (5%) had a postoperative diagnosis of Crohn's disease. Subjective functional results and anal manometry were assessed in all 14 patients in Group I (100%) and in 110 of the 117 patients in Group II (94%) whose stomas were closed at a mean followup of 24 (3-60) months. Manometry was per- formed before, and 2 and 12 months after surgery. Patients in Groups I and II reported a mean of 6.2 and 5.2 bowel movements during the day (P=NS), and 2 and 1.1 at night, respectively (P<0.05). A total of 12 (86%) patients in Group I and 104 (95%) in Group II reported perfect or almost perfect continence at night (P=NS), and 12 (93%) patients in Group I and 104 (95%) in Group II reported perfect or almost perfect continence during the day (P=NS). The preoperative mean and maximal resting pressures were similar in both groups (71.7 mmHg and 94 mmHG in Group I and 71.6 and 88 mmHg in Group II respectively; P=NS). Postoperative resting pressure changes were also similar in both groups P=NS), with a similar significant decline 2 months after surgery, which recovered by 12 months after surgery in both groups. There were no significant changes between the pre- and postoperative mean and maximal squeeze pressures in either group. The overall morbidity and mortality rates in Groups I and II were 21 and 0 per cent, and 21 and 0.8 per cent, respectively (P=NS). DSIAR in patients 60 years of age or older is as safe and is associated with as good functional and physiologic results as it is in younger patients. Thus, this procedure may be offered to older patients with expectation of good outcome.

Morbidity of medical therapy for ulcerative colitis: what are we really saving?

AIM

The true morbidity, cost and disability of medical therapy for ulcerative colitis are seldom delineated and are even less frequently compared to analogous parameters associated with surgical therapy. Therefore, we sought to assess and contrast medical versus surgical therapy for patients hospitalized due to severe ulcerative colitis.

MATERIALS AND METHODS

Patients were matched for age, duration and severity of disease based upon Truelove and Witts' activity index, colonoscopic and histologic appearance and APACHE (Acute Psychological and Chronic Health Evaluation) II scores. Morbidity, cost and disability of 20 medically treated patients who required at least one hospital admission were compared to 20 patients treated by a three stage restorative proctocolectomy. Demographic data, number of hospital admissions, length of stay, total hospital charges including consultant's, surgeon's, and anesthesiologist's fees, morbidity of each approach and disability were assessed. Statistical analysis was performed using Mann-Whitney and Fisher exact tests. Significance was considered as P < 0.05.

RESULTS

The mean age was 53.6 years in the medical group and 48.1 years in the surgical group (P = NS) and the average duration of disease was 10.5 years and 9.5 years, respectively (P = NS). The same severity of pancolitis was noted in both groups; APACHE scores of 13 and 14 in the medical and surgical groups, respectively, were noted. The total number of hospital admissions and total combined length of stay per patient in each group were not significant. Total mean hospital cost for the medical group was $28,477.00 per patient versus $33,041.00 for the three stage restorative proctocolectomy (P = NS). The mean duration of disability in the medical group was 6.4 months per patient versus 5.0 months in the surgical group (P = NS). However, patients in the medical group required more transfusions (25%) than did those in the surgical group (0%) (P < 0.05) and significant weight loss was more common in the medical group (45%) compared to the surgical group (5%) (P < 0.01). All patients in the surgical group were permanently weaned from steroids. Furthermore, while 65% of patients in the medical group had significant steroid-related complications, the major surgical complication rate was only 15% (P < 0.01).

CONCLUSION

Medical treatment was associated with a significantly higher overall morbidity than surgical therapy. Additionally, a three stage restorative proctocolectomy was performed at no additional hospital cost or subsequent disability in patients with severe ulcerative colitis. The value of prolonged medical therapy in this select group of patients is questionable.

Functional results of the double-stapled ileoanal reservoir

BACKGROUND

The preferred method for creation of an ileoanal reservoir is still controversial. We prospectively studied the functional and physiologic outcome of our patients who underwent a double-stapled ileoanal reservoir (DSIAR).

STUDY DESIGN

All consecutive patients who underwent restorative proctocolectomy with a DSIAR between 1988 and 1993 were evaluated. Functional results were assessed by questionnaires and anal manometry preoperatively and two, 12, and 24 months postoperatively.

RESULTS

One hundred forty patients (90 males and 50 females) with a mean age of 40.7 (range, 12 to 71) years were evaluated. Of these, 107 patients (77 percent) had ulcerative colitis, 21 (15 percent) had familial adenomatous polyposis, six (4 percent) had indeterminate colitis, and six (4 percent) had a post-operative diagnosis of Crohn's disease. One hundred twenty-four (95 percent) of the 131 patients with closed stomas were available for functional and manometric evaluation at a mean follow-up period of 24 months. A 32 percent decline in the mean resting pressure (from 71.3 +/- 4 to 48.2 +/- 3.4 mm Hg) occurred early after DSIAR (p < 0.001) with partial recovery by 24 months. The maximal internal sphincter resting pressure showed a 39 percent decline (from 90.8 +/- 4.9 to 55.3 +/- 5.7 mm Hg, p < 0.005) with recovery after 12 months. There were no significant changes in the length of the high-pressure zone or mean or maximal squeeze pressures. A mean of 5.4 (two to 13) bowel movements occurred during the day and a mean of 1.2 (zero to four) occurred at night. Perfect or almost perfect continence was reported during the day and night, respectively, by 95 and 92 percent of the patients. Overall perioperative complications occurred in 30 patients (21 percent) including septic complications in eight (6 percent), and pouchitis in eight (6 percent). There was one postoperative death (0.7 percent).

CONCLUSIONS

Double-stapled ileoanal reservoir is associated with good subjective functional and objective physiologic results and has acceptable rates of morbidity and mortality.

Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial

INTRODUCTION

The routine use of a nasogastric tube after elective colorectal surgery is no longer mandatory. More recently, early feeding after laparoscopic colectomy has been shown to be safe and well tolerated. Therefore, the aim of our study was to prospectively assess the safety and tolerability of early oral feeding after elective "open" abdominal colorectal operations.

MATERIALS AND METHODS

All patients who underwent elective laparotomy with either colon or small bowel resection between November 1992 and April 1994 were prospectively randomized to one of the following two groups: group 1: early oral feeding--all patients received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated; group 2: regular feeding--all patients were treated in the "traditional" way, with feeding only after the resolution of their postoperative ileus. The nasogastric tube was removed from all patients in both groups immediately after surgery. The patients were monitored for vomiting, bowel movements, nasogastric tube reinsertion, time of regular diet consumption, complications, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 mL occurred in the absence of bowel movement. Ileus was considered resolved after a bowel movement in the absence of abdominal distention or vomiting.

RESULTS

One hundred sixty-one consecutive patients were studied, 80 patients in group 1 (34 males and 46 females, mean age 51 years [range 16-82 years]), and 81 patients in group 2 (43 males and 38 females, mean age 56 years [range 20-90 years]). Sixty-three patients (79%) in the early feeding group tolerated the early feeding schedule and were advanced to regular diet within the next 24 to 48 hours. There were no significant differences between the early and regular feeding groups in the rate of vomiting (21% vs. 14%), nasogastric tube reinsertion (11% vs. 10%), length of ileus (3.8 +/- 0.1 days vs. 4.1 +/- 0.1 days), length of hospitalization (6.2 +/- 0.2 days vs. 6.8 +/- 0.2 days), or overall complications (7.5% vs. 6.1%), respectively, (p = NS for all). However, the patients in the early feeding group tolerated a regular diet significantly earlier than did the patients in the regular feeding group (2.6 +/- 0.1 days vs. 5 +/- 0.1 days; p < 0.001).

CONCLUSION

Early oral feeding after elective colorectal surgery is safe and can be tolerated by the majority of patients. Thus, it may become a routine feature of postoperative management in these patients.

Pudendal neuropathy in evacuatory disorders

PURPOSE

Aims of the present study were to assess frequency of pudendal neuropathy in patients with constipation and fecal incontinence, to determine its correlation with clinical variables, anal electromyographic assessment, and anal manometric pressures, and to determine usefulness of the pudendal nerve terminal motor latency assessment in evaluation of these evacuatory disorders.

METHODS

From 1988 to 1993, 395 patients (constipated, 172; incontinent, 223) underwent pudendal nerve terminal motor latency, electromyography, and anal manometry. Pudendal neuropathy was defined as a pudendal nerve terminal motor latency greater than 2.2 ms.

RESULTS

Patients were a mean age of 60.7 (range, 17-88) years. Overall incidence of pudendal neuropathy was 31.4 percent (constipated, 23.8 percent; incontinent, 37.2 percent; P < 0.05). Incidence of pudendal neuropathy dramatically increased after 70 years of age in both groups (22 percent vs. 44 percent; P < 0.05). Moreover, subjects with pudendal neuropathy were older than those without pudendal neuropathy (mean age, 67 vs. 57 years; P < 0.05). The presence of pudendal neuropathy was associated with decreased motor unit potentials recruitment in patients with incontinence (P < 0.01). Patients with and without pudendal neuropathy had a similar mean squeezing pressure in both groups.

CONCLUSION

Pudendal neuropathy is an age-related phenomenon. Although pudendal neuropathy is associated with abnormal anal electromyographic findings in patients with incontinence, no association with anal manometric pressures was found. Pudendal nerve terminal motor latency assessment is a useful tool in the evaluation of patients with fecal incontinence, but its role in the assessment of constipated patients remains unknown.

Effect of xylene clearance of mesenteric fat on harvest of lymph nodes after colonic resection

OBJECTIVE

To find out if clearance of surgical colectomy specimens with xylene gave a higher yield of lymph nodes and more accurate staging than the traditional step-sectioning technique.

DESIGN

Consecutive open study.

SETTING

Private hospital, United States.

MATERIAL

84 specimens from colonic resections, 4 of which were total colectomies and the remaining 80 segmental resections.

INTERVENTIONS

The first 41 (2 colectomies and 39 segmental resections) were cleared by step-sectioning alone (to establish baseline values). The remainder (n = 2 and 41, respectively) were step-sectioned, the lymph nodes were removed, and then the residual tissue was cleared with xylene.

MAIN OUTCOME MEASURES

The number of lymph nodes found, and if the diagnosis was changed by the finding of additional nodes.

RESULTS

The baseline values in the two total colectomy specimens were 76 and 101, and the mean (range) after segmental colectomy was 21 (1-98). The values after total colectomy in the second group were 33 and 73, and after xylene clearance an additional 12 and 17 nodes were found. After segmental colectomy a mean (range) of 13 (0-43) was found, and an additional 4 (0-12) were found after xylene clearance. No additional nodes containing metastases were found in total colectomy specimens after xylene clearance, and only 6 additional nodes after segmental resection contained metastases. These changed the histological stage of the disease in only 2 patients.

CONCLUSIONS

Xylene clearance offers little advantage over careful traditional step-sectioning of specimens, but may be of value if the histopathologist does not do routine meticulous step-sectioning.

Colonoscopic-assisted laparoscopic colectomy

One of the technical difficulties during laparoscopic and laparoscopic-assisted resection of the right, transverse, and left colon is the mobilization of the splenic and hepatic flexures. We present a simple technique of colonoscopic traction of the splenic or hepatic flexure. This technique enables good exposure and facilitates dissection while laparoscopic mobilization of these segments of the colon is performed.