External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano

BACKGROUND

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.

METHODS

This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.

RESULTS

Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.

CONCLUSIONS

ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Does caffeine enhance bowel recovery after elective colorectal resection? A prospective double-blinded randomized clinical trial

BACKGROUND

Postoperative ileus is a common condition following abdominal surgery. Previous studies have shown the positive effects of coffee on gastrointestinal motility. The aim of this study was to assess whether caffeine is the stimulatory agent in coffee that triggers bowel motility and thus may reduce the duration of postoperative ileus.

METHODS

This was a single-centered, prospective, randomized controlled, double-blinded clinical trial. Patients scheduled to undergo elective laparoscopic colectomy between November 2017 and March 2019 were randomly assigned to receive either oral caffeine (100 mg three times daily) or placebo following the procedure. Primary endpoints were time to first flatus and time to first bowel movement. Secondary endpoints were time to tolerate a solid, low-residue diet and length of hospital stay. Registration number: NCT03097900.

RESULTS

Seventy patients were included, [35 males, median age 56 years (range 19-79 years)]. After the exclusion of 12 patients, there were 30 patients in the caffeine group and 28 patients in the placebo group. The first passage of stool in the caffeine group occurred 18 h earlier than in the placebo group (p = 0.012); other endpoints did not reach statistical significance. No caffeine-related adverse events were observed.

CONCLUSION

Caffeine consumption following colectomy is safe, leads to a significantly shorter time to first bowel movement, and may thus potentially lead to a shorter postoperative hospital stay.

Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty

BACKGROUND

The management of full thickness rectal prolapse remains controversial. Although abdominal approaches have a lower recurrence rate than do perineal operations, they are associated with a higher morbidity. The aim of this study was to compare the outcomes of perineal rectosigmoidectomy with and without levatorplasty.

METHODS

Between 1989 and 1999, a total of 109 consecutive patients (10 men) underwent 120 perineal procedures. These patients were retrospectively evaluated in two groups on the basis of the type of surgery received: perineal rectosigmoidectomy (PRS) or perineal rectosigmoidectomy with levatorplasty (PRSL). Subsequent functional outcome and physiological parameters were assessed.

RESULTS

The patients had a mean age of 75.7 years (range, 23.0-94.8 years) and they were followed for an overall mean (in both groups combined) of 28.0 months (range, 0.4-126.4 months) after surgery. Mean duration of surgery was 78.1 min (SD=25.9) and 97.6 min (SD=32.3) in PRS and PRSL, respectively ( p=0.002, unpaired t test). There was no significant difference between the two groups in terms of hospital stay, morbidity or mortality. Recurrence rates and mean time interval to recurrence were, respectively, 20.6% and 45.5 months in PRS compared to 7.7% and 13.3 months in PRSL ( p=0.049, chi-square test; p=0.001, unpaired t test). Both groups had significant improvements in postoperative incontinence score ( p<0.0001, Wilcoxon's matched-pairs signed-ranks test), however, there were no significant changes in anorectal manometric findings and pudendal nerve terminal motor latency assessment.

CONCLUSIONS

Perineal rectosigmoidectomy with levatorplasty is associated with a lower recurrence rate and a longer time to recurrence than perineal rectosigmoidectomy alone. Levatorplasty should be offered to patients when a perineal approach for rectal prolapse is selected.

Current attitudes in laparoscopic colorectal surgery

BACKGROUND

In this study, we set out to examine the current attitudes among surgeons toward laparoscopic colorectal surgery (LCS).

METHODS

A total of 3628 questionnaires were sent to all North American members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS); 40% of the members of each society responded (B15 respondents).

RESULTS

Currently, 85% of the respondents perform laparoscopic surgery; LCS was performed by 48% of the respondents in 21% of their patients. Although 35% of the members of SAGES have increased the number of laparoscopic colorectal operations they perform in the last 3 years, only 26% of ASCRS members did so. Our findings showed that 74% of the surgeons who perform LCS do so for diverticular disease, 68% for colonic polyps, 61% for villous adenoma, and 36% for ileal Crohn's disease. However, only 15% operate for the cure of carcinoma of any stage (16% of SAGES members and 11% of ASCRS members), whereas 8.5% and 7% operate for the cure of all upper and lower rectal carcinomas, respectively. Thirty-six percent of the surgeons who perform LCS for cancer have done between one and 10 curative resections, 8% have done 11-20 procedures, and 14% have done >20 procedures. There were 80 cases of port site recurrence reported by 4.4% of surgeons. Although 56% of the respondents would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 9% would do so for a distal-third rectal carcinoma (12% of SAGES and 5% of ASCRS respondents).

CONCLUSIONS

The overall percentage of respondents performing LCS has decreased over the last 3 years; moreover, surgeons are more hesitant to perform laparoscopic surgery for the cure of colonic cancer. Due to the overall low response rate, the fact that 4.4% of those surgeons who did respond have seen port site recurrences does not allow any conclusions to be drawn about the prevalence of this problem.

Intraoperative endoscopy in laparoscopic colectomy

BACKGROUND

The localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy.

METHODS

We did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon.

RESULTS

Between 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group ( p = 0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications.

CONCLUSION

Intraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.

Is obesity a high-risk factor for laparoscopic colorectal surgery?

BACKGROUND

The aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures.

METHODS

All 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality.

RESULTS

Thirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p = 0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% versus 24% in the nonobese group (p <0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs. 7.6% (p <0.01) and 12.9 vs 3.1%. (p = 0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p = 0.02).

CONCLUSION

Laparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.

Laparoscopic total mesorectal excision

After total mesorectal excision for rectal cancer was introduced in 1982, local recurrence rates decreased to 5%. These results were found to be reproducible; therefore, the technique became standard for the treatment of rectal cancer. Laparoscopic surgery for curable colorectal malignancy is still considered investigational. Indeed, the United States National Cancer Institute (NCI) trial excludes rectal carcinoma. The application of laparoscopy to rectal carcinoma must compete with total mesorectal excision, which has obtained favorable results in the last decade. In this review, we assess the adequacy of laparoscopic total mesorectal excision, describe the techniques (both anterior resection and abdominoperineal resection), and discuss their potential advantages.

The efficacy of chemoradiation therapy in HIV seropositive patients with squamous cell carcinoma of the anus

OBJECTIVE

The aim was to assess the efficacy of chemoradiation therapy for squamous cell carcinoma of the anal canal in HIV seropositive patients.

PATIENTS AND METHODS

A retrospective review of all patients with squamous cell carcinoma of the anus treated primarily with combined chemotherapy (5-fluorouracil and mitomycin) and radiotherapy or local excision was undertaken comparing HIV seropositive to HIV seronegative patients.

RESULTS

Thirteen HIV seronegative patients were compared with 6 HIV seropositive patients. The HIV positive group included a higher proportion of males and a significantly greater history of prior treatment for condyloma. There was no difference in the median radiation dose (5020 cGy vs 4500 cGy, P=0.10). There was a trend towards higher local tumour recurrence in the HIV seropositive patients although this was not statistically significant (30% vs 66%). The CD4 count of HIV positive patients did not correlate either with their ability to complete the prescribed treatment regimen or with subsequent recurrence.

CONCLUSION

Combined chemoradiation is feasible in HIV positive patients, however, local recurrence rates in HIV positive patients may be higher. Tolerance of this therapy in HIV seropositive patients or recurrence after therapy are not related to the patient's CD4 cell count.

Bowel preparation for colorectal surgery

PURPOSE

The aim of this study was to assess recent literature regarding bowel preparation for colonoscopy and surgery.

METHODS

The study was conducted by an Index Medicus English-language search of articles relevant to both oral mechanical and parenteral and oral antibiotic preparation for elective colorectal surgery and mechanical bowel preparation for colonoscopy. The study period was from 1975 to 2000. In addition, studies of elective colorectal surgery without mechanical bowel preparation were also considered.

RESULTS

Although several recent prospective, randomized trials have suggested that elective colorectal surgery can be safely performed without any mechanical bowel preparation, mechanical bowel preparation remains the standard of care, at least in North America at the present time. A recent survey of the members of The American Society of Colon and Rectal Surgeons revealed that the majority currently use sodium phosphate for bowel preparation and use a dual oral antibiotic regimen before elective colorectal surgery, combined with two doses of parenteral antibiotics. Although some of the use patterns are based on prospective, randomized study, others seem founded strictly on habit and theory.

CONCLUSIONS

The current methods of bowel cleansing for both colonoscopy and surgery include sodium phosphate and polyethylene glycol; colorectal surgeons practicing in North America currently prefer sodium phosphate. Additional preparation for colorectal surgery includes perioperative parenteral antibiotics and, to a slightly lesser degree, preoperative oral antibiotic preparation. Although some recent prospective, randomized studies have suggested that omission of mechanical bowel preparation for elective colorectal surgery is not only feasible but potentially preferable, caution is recommended before routinely omitting these widely practiced measures, because data to support such routine omission are limited.

Effect of age on the functional outcome of total abdominal colectomy for colonic inertia

OBJECTIVE

Colonic inertia (CI) usually presents in women in the third decade of life; however, elderly patients are at times diagnosed with the disease. Total abdominal colectomy (TAC) is considered the preferred surgical treatment for patients with well established CI refractory to conservative and medical management. Surgeons are reluctant to proceed with colectomy in aged patients because of anticipated high morbidity and poor functional outcome.

MATERIALS AND METHODS

We retrospectively reviewed the outcome in 14 patients over the age of 65 years (range 65-80) (Group I) who underwent TAC for CI between 1988 and 1996. The functional and clinical outcome was compared with that of 41 patients under the age of 65 (range 21-61) (Group II) operated upon during the same time period. Functional outcome was assessed by postal and telephone questionnaires at least 12 months following surgery.

RESULTS

There was no major postoperative morbidity in either group. Three (21%) patients in Group I developed small bowel obstruction postoperatively and, of them, 2 required surgical treatment. In Group II the rate of obstruction was 7% (3 patients), with one patient requiring surgery. One patient in Group I subsequently underwent completion proctectomy and creation of an end ileostomy due to continued panenteric hypomotility. Three patients in Group I died during follow-up from causes unrelated to surgery. The mean frequency of spontaneous bowel movements following surgery was 3.8 (range 1-10)/day in Group I and 2.9 (range 1-8)/day in Group II (P=NS). 'Excellent' outcome was reported by 7 patients (64%) in Group I and 39 patients (95%) in Group II (P=0.01).

CONCLUSION

TAC can be performed in elderly patients with established CI with acceptable functional results and no increase in morbidity, resulting in lifestyle improvement. Complete physiological evaluation with increased emphasis on small bowel and gastric motility studies is required in this patient population.

Adenocarcinoma arising from along the rectal stump after double-stapled ileorectal J-pouch in a patient with ulcerative colitis: the need to perform a distal anastomosis. Report of a case

Patients treated with restorative proctocolectomy for ulcerative colitis occasionally develop neoplasia from the rectal mucosal remnants. We report a case of a 65-year-old male who developed an adenocarcinoma from the rectal stump after a double-stapled ileorectal J-pouch for ulcerative colitis. We emphasize the need to perform the anastomosis either at the level of the dentate line or just cephalad to the anal transitional zone. Furthermore, when high-grade dysplasia at the rectum is evident, either an ileal pouch-anal anastomosis with mucosectomy or completion proctectomy with an end Brooke ileostomy should be offered. This is the second report in the literature of a carcinoma arising after use of the double-stapled ileal pouch-anal anastomotic technique.

Update on prospective randomized trials of laparoscopic surgery for colorectal cancer

Cosmetic improvement is perhaps the only conclusive advantage of laparoscopic colectomy for cancer. Previous retrospective studies repeatedly have demonstrated the feasibility and safety of this procedure. Although short-term prospective studies showed adequate cancer resection, comparable complication rates, and no increase in recurrence, issues of port site implantation, immune response and cost-efficiency remain unsolved. The ongoing clinical trials mentioned currently are evaluating the benefits and the potential risks of this technique as a cancer operation. Four trials will have completed accrual and three will be able to offer early analysis of the results by the year 2001. Until then, laparoscopic surgery for colorectal cancer should be considered investigational to be performed only as part of these above-mentioned trials.

Are complications of subtotal colectomy with ileorectal anastomosis related to the original disease?

The aim of this study was to compare the morbidity of subtotal colectomy with ileorectal anastomosis performed for colonic inertia, Crohn's disease, familial adenomatous polyposis, and colorectal neoplasia. A retrospective review of all patients who underwent elective colectomy with ileorectal anastomosis between June 1988 and November 1996 was performed. The patients were divided into three groups: Group I, colonic inertia; Group II, Crohn's disease; and Group III, Familial Adenomatous Polyposis or other neoplasia. Outcome factors studied included the frequency of bowel movements, the incidence of small bowel obstruction, and the incidence of anastomotic leakage. Other factors assessed included operative time, intraoperative blood loss, length of hospitalization, level of ileorectal anastomosis, time of first bowel movement, and whether the operation was undertaken in one or two stages. Statistical analysis was undertaken by using the chi-square test and the Mann-Whitney U exact test. All 48 patients in Group I were operated on in one stage. In Group II (30 patients) 15 patients were operated on in one stage, eight patients had a preliminary Hartmann's operation and then ileorectal anastomosis, and seven patients underwent subtotal colectomy with both an ileorectal anastomosis and a proximal loop ileostomy. In Group III (22 patients) 20 patients underwent a one-stage operation whereas two patients underwent a subtotal colectomy with ileorectal anastomosis and proximal loop ileostomy. The median ages were 47.0 years in Group I, 43.8 in Group II, and 53.3 in Group III. Small bowel obstruction occurred in five patients (10%) in Group I, four patients (13.3%) in Group II, and four patients (18%) in Group III. The anastomotic leak rate was 4.2% (two patients) in Group I, 1% (three patients) in Group II, and 0% in Group III (P < 0.05). At the follow up interview after surgery, the mean number of bowel movements per day 6 months after surgery was 5.4 in Group I, 7.2 in Group II, and 5.6 in Group III, (P < 0.05, Group II vs Group I or Group III). Operative time in Group III was significantly longer than in the other two groups (P = 0.004). No statistically significant differences were found among the three groups relative to blood loss, hospitalization, or timing of first bowel movement. This study failed to identify any differences in either immediate perioperative outcome or morbidity or intermediate-term function in patients undergoing ileorectal anastomosis regardless of diagnosis. The overall rate of small bowel obstruction was 13 per cent with no significant differences among the three groups. Lastly although the anastomotic leak rate was not significantly higher in patients with Crohn's disease it was higher in the group with ileostomy and ileorectal anastomosis, which highlights a potential advantage of performance of this procedure in two stages in selected patients of this patient population.

Outcome and management of patients with large rectoanal intussusception

OBJECTIVES

Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome.

METHODS

Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception > or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse.

RESULTS

Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12-118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37-91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0-5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group 1 (8.1+/-2.8 vs 0.8+/-0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7+/-4.2 to 1.1+/-5.4 vs 1.4+/-2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse.

CONCLUSIONS

This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.

Long-term follow-up of patients undergoing colectomy for colonic inertia

PURPOSE

Total abdominal colectomy with ileorectal anastomosis has been the procedure of choice for patients with the established diagnosis of colonic inertia. Previous studies with a limited follow-up of only one to two years have shown acceptable results and a high rate of patient satisfaction. The aim of this study was to evaluate the long-term results of total abdominal colectomy in these patients in terms of complications, bowel function, and overall patient satisfaction.

METHODS

Access to the colorectal registry at the Cleveland Clinic Florida identified all patients who underwent total abdominal colectomy for colonic inertia between 1988 and 1993, with a minimum of five-year follow-up. Telephone interviews were designed to assess bowel function, concomitant use of any antidiarrheal medications, postoperative complications, persistence or development of preoperative symptoms such as pain or bloating, and overall satisfaction. Patients were asked to rate their outcome as excellent, good, fair, or poor.

RESULTS

Fifty patients underwent total abdominal colectomy for the diagnosis of colonic inertia. Three patients died of unrelated causes and 30 (60 percent) were available for follow-up. The mean follow-up was 106 months, ranging from 61 to 122 months. All 30 patients reported the outcome of surgery as "excellent." The average frequency of spontaneous bowel movements was 2.5 (range, 1-6) per day. During the period of follow-up, six patients (20 percent) required admission for small-bowel obstruction, three of whom (10 percent) required laparotomy. Four patients complained of mild pelvic pain, only one of whom had the onset of pelvic pain postoperatively that persisted until the time of interview. In the other three patients the pain was present preoperatively but had decreased in intensity since the operation. Two patients (6 percent) still required assistance with bowel movements, one by laxatives and the other by enemas. Only two patients (6 percent) needed antidiarrheal medications to reduce bowel frequency.

CONCLUSION

This long-term follow-up revealed a high degree of patient satisfaction and very good bowel habits, with an acceptable long-term rate of bowel obstruction. Based on these results, total abdominal colectomy can be recommended to patients with well-established colonic inertia with expectations of sustained benefit up to ten years after surgery.

Reproducibility of colonic transit study in patients with chronic constipation

PURPOSE

Major therapeutic decisions are rendered based on a single colonic transit study. Therefore, the aim of this study was to assess the reproducibility of colonic transit time in patients with chronic constipation.

MATERIALS AND METHODS

Fifty-one patients with chronic idiopathic constipation were randomly selected to undergo two separate colonic transit tests. All clinical conditions, methodology, and patients' instructions were identical on both occasions. The gamma rate (linear correlation analysis) was undertaken between the first and second colonic transit times. Groups were divided according to the diagnoses of colonic inertia (slow-transit constipation), paradoxical puborectalis contraction, and chronic idiopathic constipation (normal-transit constipation).

RESULTS

In 35 of 51 patients (69 percent), the results were identical between the two studies; however, in 16 patients (31 percent), the results were disparate (gamma correlation coefficient = 0.53; P < 0.01). The specific correlation coefficients for patients with colonic inertia, paradoxical puborectalis contraction, and chronic idiopathic constipation were 0.12, 0.21, and 0.60 (P < 0.01), respectively. Moreover, the success rate of colectomy for colonic inertia was significantly higher in patients who underwent a repeat transit study confirming inertia than in patients who underwent colectomy based on a single study.

CONCLUSIONS

Overall, colonic transit time is reproducible in patients with chronic constipation. The correlation coefficient is best for patients with idiopathic constipation and worst for patients with colonic inertia. This new finding suggests that suboptimal surgical outcome may be attributable to inaccurate diagnosis. Because of this poor correlation coefficient, in patients with colonic inertia, consideration should be given to repeating the colonic transit study before colectomy to help secure the diagnosis and improve outcome.

Mallory-Weiss syndrome: possible link to water immersion and subsequent air flight

Mallory-Weiss Syndrome (MWS) lesions account for up to 15 per cent of upper gastrointestinal bleeding episodes. Typically these lesions present as a consequence of vomiting that is often associated with alcoholism. Recently other conditions such as pregnancy, migraine, hiatal hernia, gastric ulcer, biliary disease, and various medications have been associated with MWS. We report on a 32-year-old male who developed a MSW lesion after a prolonged period of swimming followed by an extended commercial airplane flight. The hemodynamic changes associated with swimming (increased central distribution of blood volume) and the pressure changes in commercial aircraft (a reduction of 0.3 atmospheres of pressure) are discussed. We conclude that the combination of these factors contributed to the development of a MWS lesion and gastrointestinal bleeding in this patient. We recommend that both air travel and athletic activities be considered as possible contributing factors in the evaluation of the cause of new-onset gastrointestinal bleeding.

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique: is there a relation to tissue type?

PURPOSE

The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut.

METHODS

Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouchanal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I- patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II- patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery.

RESULTS

Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12-132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13-79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups.

CONCLUSIONS

The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.

Recurrent rectal prolapse: what is the next good option?

PURPOSE

The aim of this study was to assess the clinical and functional outcome of surgery for recurrent rectal prolapse and compare it with the outcome of patients who underwent primary operation for rectal prolapse.

METHODS

All patients who underwent surgery for rectal prolapse were evaluated for age, gender, procedure, anorectal manometry and electromyography findings, and morbidity. The results for patients who underwent surgery for recurrent rectal prolapse were compared with a group of patients matched for age, gender, surgeon, and procedure who underwent primary operations for rectal prolapse.

RESULTS

A total of 115 patients underwent surgery for rectal prolapse. Twenty-seven patients, 10 initially operated on at this institution and 17 operated on elsewhere, underwent surgery for recurrent rectal prolapse. These 27 patients were compared with 27 patients with primary rectal prolapse operated on in our department. In the recurrent rectal prolapse group, prior surgery included rectopexy in 7 patients, Delorme's procedure in 7 patients, perineal rectosigmoidectomy in 7 patients, anal encirclement procedure in 4 patients, and resection rectopexy in 2 patients. Operations performed for recurrence were perineal rectosigmoidectomy in 14 patients, resection rectopexy in 8 patients, rectopexy in 2 patients, pelvic floor repair in 2 patients, and Delorme's procedure in 1 patient. There were no statistically significant differences between the groups in preoperative incontinence score (recurrent rectal prolapse, 13.6 +/- 7.8 vs. rectal prolapse, 12.7 +/- 7.2; range, 0-20) or manometric or electromyography findings, and there were no significant differences in mortality (0 vs. 3.7 percent), mean hospital stay (5.4 +/- 2.5 vs. 6.9 +/- 2.8 days), anastomotic complications (anastomotic stricture (0 vs. 7.4 percent), anastomotic leak (3.7 vs. 3.7 percent) and wound infection (3.7 vs. 0 percent), postoperative incontinence score (2.8 +/- 4.8 vs. 1.5 +/- 2.7), or recurrence rate (14.8 vs. 11.1 percent) between the two groups at a mean follow-up of 23.9 (range, 6-68) and 22 (range, 5-55) months, respectively. The overall success rate for recurrent rectal prolapse was 85.2 percent.

CONCLUSION

The outcome of surgery for rectal prolapse is similar in cases of primary or recurrent prolapse. The same surgical options are valid in both scenarios.

Do prior abdominal operations alter the outcome of laparoscopically assisted right hemicolectomy?

BACKGROUND

Adhesions can increase the difficulty of both laparoscopic surgery and laparotomy. The aim of this study was to compare the results of laparoscopically assisted right hemicolectomy in patients after prior abdominal operations (PAOs) with the results in patients without prior abdominal operations (NPAOs).

METHODS

Between August 1991 and September 1998, 85 patients underwent laparoscopically assisted right hemicolectomy. The Mann-Whitney test or Fisher's exact test was used for statistical analysis.

RESULTS

In this study, 36 patients (21 women and 15 men), with an average age of 57.5 years (range, 15-87 years) had undergone a mean of 1.25 (range, 1 to 3) PAOs, whereas 49 patients (20 women and 29 men), with an average age of 60.0 years (range, 16 to 87 years) (p = 0.44) had undergone NPAOs. Overall in the PAO and NPAO groups, respectively, there were no significant differences in the incidence of intraoperative complications (3 versus 4; p = 1.0). The mean operative time was 151 min (range, 90 to 260 min) versus 148 min (range, 70 to 270 min) (p = 0.66), and the mean length of stay was 6. 8 days (range, 3 to 18 days) versus 7.6 days (range, 3 to 19 days) (p = 0.13). The procedure was converted to laparotomy (p = 0.754) for six patients in the PAO group (5 because of adhesions) and 6 patients in the NPAO-group (1 because of adhesions; p = 0.078). In the PAO group 17 patients (47%) had 22 postoperative complications: 11 general medical and 4 wound-related complications. Seven patients (19%) had prolonged postoperative ileus. In the NPAO-group 18 patients (38%) had a total of 22 complications: 7 general medical problems, 6 wound-related complications, and 8 prolonged postoperative ileus, none of which were statistically significant. One patient in the NPAO group had an anastomotic leak. During a mean follow-up period of 41 months (range, 3 to 89 months), three patients in the PAO group and four in the NPAO group developed incisional hernias.

CONCLUSIONS

Although there is a trend toward more conversions because of adhesions in patients with a history of prior abdominal operations (p = 0.078), no increase in morbidity resulted. Therefore, laparoscopically assisted right hemicolectomy can be offered to patients with PAO, whose rate of adhesions can be expected to equal that of patients with NPAO.

Complications following formalin installation in the treatment of radiation induced proctitis

Formalin installation has been safely and effectively used to treat refractory bleeding caused by radiation proctitis. This study evaluated the results of such treatment in terms of outcome and complications. All four patients who underwent formalin irrigation for transfusion-dependent radiation proctitis over a 15-month period were evaluated retrospectively. The procedure was performed under sedation in the operating room, with patients in the prone jack-knife position. A solution of 4% formalin was introduced in aliquots of 50 ml kept in contact with the mucosa for 30 s and then cleared away using saline irrigation; five to six aliquots were used in each session. In a fifth patient formalin-soaked gauze pads were applied directly to the injured mucosa. At a mean follow-up of 18 months (range 6-26) two patients had repeat episodes of bleeding, one underwent successful repeat irrigation, and the other refused further treatment. One patient suffered from severe anococcygeal pain and worsening of incontinence after the procedure. The pain was treated with lidocaine ointment and sitz baths with partial success. Another patient developed severe formalin-induced colitis 5 days after the procedure, which required intravenous antibiotics and hydration. Formalin installation may be effective in controlling refractory bleeding due to radiation induced proctitis. The procedure, however, is not risk free and may induce major complications such as acute colitis.

A prospective randomized trial comparing four biofeedback techniques for patients with faecal incontinence

OBJECTIVE

The aim of this study was to compare four methods of biofeedback therapy for patients with faecal incontinence (FI).

PATIENTS AND METHODS

All patients with FI who were ineligible for surgical management were prospectively randomized using a computer generated randomization method into one of four protocols: 1, out-patient intra-anal electromyographic biofeedback training (EMG); 2, EMG plus intrarectal balloon training (BT); 3, EMG plus a home trainer (HT); and 4, EMG, BT and HT. All patients received weekly, 1 h, out-patient biofeedback training. Success for patients with FI was measured by a reduction in incontinent episodes (days/week). In all instances, patients maintained a daily log in which documentation was recorded regarding each bowel evacuation.

RESULTS

Forty patients were randomized into one of the four groups. Six patients withdrew after one session and were not included in the analysis. Therefore, 34 patients (23 female and 11 male) with a mean incontinence score of 12 (range 7-14) were randomized to one of the four groups (n=8, 8, 8, and 10, respectively). There was a statistically significant reduction in incontinent episodes for all groups. However, there were no significant differences in treatment outcome found in comparisons among the four groups.

CONCLUSION

Biofeedback therapy significantly improves FI. Moreover, EMG training was as effective alone as was the addition of HT, BT or both for the treatment of FI.

Overcoming Wallstent malposition in the treatment of rectosigmoid obstruction

In recent years, the use of transanal stenting of malignant colonic strictures for the palliation of obstructive symptoms has increased. Due to the rectosigmoid angle, stenting sigmoid tumors is more troublesome than rectal lesions, but the difficulty may be overcome by using a two-team approach. The radiologist assists the endoscopist with the use of fluoroscopy to ensure proper positioning of both the colonoscope and the stent. The most common complication is stent migration, but stent obstruction and colonic perforation may also occur. We treated a woman suffering from metastatic gastric cancer with peritoneal metastases by creating a 12-cm stricture in the sigmoid colon. Two adjoining Wallstents were required to bridge the obstruction. Following migration of the proximal stent, a third stent was introduced to bridge the previous two stents with satisfactory outcome.

Use of bioresorbable membrane (sodium hyaluronate + carboxymethylcellulose) after controlled bowel injuries in a rabbit model

PURPOSE

Patients in whom enterolysis is performed are at high risk for recurrence of adhesions and for injury during adhesiolysis. Therefore, the aim of this study was to assess the safety of sodium hyaluronate-based bioresorbable membrane (Seprafilm) after myotomy and enterotomy.

METHODS

A total of 60 rabbits underwent laparotomy with equal distribution to one of three groups: creation of either three repaired, or three unrepaired myotomies, or three repaired enterotomies. Thus, a total of 180 defects were created in the same anatomic positions. One-half of the animals in each group had the surface of the myotomies or enterotomies covered by Seprafilm. Fourteen days later, after complete absorption of Seprafilm, the presence of intra-abdominal abscess, adhesions, and the integrity of the suture line were evaluated by a surgeon blinded to the use of Seprafilm and by a standard radiographic isobaric contrast study. Statistical analysis was done by use of Fisher's exact test; significance was set at P < 0.05.

RESULTS

The incidence of adhesions in the repaired myotomy group were 2 (6.6 percent) and 9 (30 percent) in the Seprafilm and control (nonSeprafilm) groups, respectively (P < 0.05); in the unrepaired myotomy group, 2 (6.6 percent) and 10 (33 percent) in the Seprafilm and control groups, respectively (P < 0.05); and in the enterotomy group, 28 (94 percent) and 29 (97 percent) in the Seprafilm and control groups, respectively (P = not significant). A single phlegmon occurred in the myotomy group at a Seprafilm site (1.6 (1/60) vs. 0 percent, P = not significant). There were no leaks in this group. In the enterotomy group, the incidence of phlegmons was 33 percent (10/30) in the Seprafilm group, whereas it was 27 percent (8/30) in the nonSeprafilm group (P = not significant). The incidence of leaks was 6.6 (2/30) and 10 percent (3/30) in the Seprafilm and nonSeprafilm group, respectively (P = not significant).

CONCLUSION

The use of Seprafilm at the sites of myotomies significantly reduced the incidence of adhesions. Effectiveness at the enterotomy site may have been attenuated by a greater inflammatory response. Importantly, Seprafilm did not increase septic mortality in any group.

Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus

PURPOSE

The aim of this study was to compare the length of postoperative ileus in patients undergoing colectomy by either laparotomy or laparoscopy.

METHODS

A total of 166 patients were studied. These patients were divided into two groups: Group 1, in which colectomy was done laparoscopically, and Group 2, consisting of patients undergoing laparotomy. Both groups contained 83 patients who were matched for disease severity, indications for surgery, and procedure. Indications for surgery included sigmoid diverticulitis in 12 (14 percent) patients, polyps in 22 (27 percent), Crohn's disease in 21 (25 percent), colorectal cancer in 11 (13 percent), stoma reversal in 8 (10 percent), rectal prolapse in 3 (4 percent), and other indications in 6 (7 percent) in each group. Operations were colectomy with anastomosis (42 ileocolic, 26 colorectal, 6 colocolic, 4 ileorectal, and 2 ileal J pouch) or without anastomosis (3 abdominoperineal resections) performed by the same surgeons during the same time period January 1993 to October 1996). The nasogastric tube was removed from all patients immediately after surgery in both groups. All patients received a clear liquid diet on the first postoperative day, followed by a regular diet as tolerated. The nasogastric tube was reinserted if two or more episodes of emesis of more than 200 ml occurred in the absence of bowel movement. Patients were discharged from the hospital when tolerating a regular diet without evidence of ileus. Statistical analysis was performed using unpaired t-test and Fisher's exact probability test.

RESULTS

The male-to-female ratio was 38 to 45 in both groups. A total of 10 (12 percent) and 23 (28 percent) patients in Group 1 and Group 2 had emesis (P = 0.02), and the rate of nasogastric tube reinsertion was 5 (6 percent) and 13 (16 percent), respectively (P > 0.05). There were significant differences between Groups 1 and 2 relative to the lengths of ileus (3.5 +/- 1.3 vs. 5.4 +/- 1.7 days, respectively; P < 0.001), hospitalization (6.6 +/- 3.3 vs. 8.1 +/- 2.5 days, respectively; P < 0.002), and operative time (170 +/- 60 vs. 114 +/- 46 minutes, respectively; P < 0.001). The morbidity rate was 16 (19.2 percent) and 18 (21.6 percent) in the laparoscopy and laparotomy groups, respectively.

CONCLUSIONS

Although early oral intake is safe and can be tolerated by 84 percent of patients after colectomy by laparotomy, laparoscopic colectomy reduced the lengths of both postoperative ileus and hospitalization.

Prospective, randomized trial comparing four biofeedback techniques for patients with constipation

PURPOSE

The aim of this study was to compare four methods of biofeedback for patients with constipation.

METHODS

Thirty-six patients were prospectively, randomly assigned to one of four protocols: 1) outpatient intra-anal electromyographic biofeedback training; 2) electromyographic biofeedback training plus intrarectal balloon training; 3) electromyographic biofeedback training plus home training; or 4) electromyographic biofeedback training, balloon training, and home training. All 36 patients received weekly one-hour outpatient biofeedback training. Success was measured by increased unassisted bowel movements and reduction in cathartic use. In all instances patients maintained a daily log in which documentation was maintained regarding each bowel evacuation and the need for any cathartics. RESULTS; There was a statistically significant increase in unassisted bowel movements for Groups 1, 2, and 4 (P < 0.05) and a reduction in the use of cathartics in Groups 1, 2, and 3 (P < 0.05).

CONCLUSION

There was a significant improvement in outcome after all four treatment protocols for constipation; however, no significant difference was found among the treatments. Therefore, electromyographic biofeedback training alone is as effective as with the addition of balloon training, home training, or both.

Reconstruction of replaced right hepatic artery, to implant a single-catheter port for intra-arterial hepatic chemotherapy

Intra-arterial hepatic chemotherapy using an implantable subcutaneous port with a catheter inserted into the gastroduodenal artery is an acceptable treatment for patients with isolated, nonresectable liver metastases from colorectal cancer. Because of the common variations of hepatic arterial anatomy occurring in about one-half of the patients, this technique will result in complete perfusion of both hepatic lobes only in those with "classical" arterial anatomy (Michels type I). Many techniques have been described in these situations, usually using a dual-catheter port with the attendant risk of hepatic misperfusion and arterial thrombosis. We herein describe an alternative technique applicable to patients with a right hepatic artery arising from the superior mesenteric artery. In this technique the right hepatic artery is anastomosed end-to-end with the gastroduodenal artery, followed by implantation of a single-catheter port that is inserted into the splenic artery.

Bladder outlet obstruction by a lymphocele following kidney transplantation

Lymphocele is a well-known complication of kidney transplantation. Patients usually present with deteriorating renal function, hydronephrosis, a nontender lower abdominal mass or ipsilateral leg edema. Urinary retention, however, is an unusual presentation of lymphocele. We herein report a case of a female patient who developed chronic urinary retention due to a pelvic lymphocele after kidney transplantation.

Pancreaticogastrostomy after pancreatoduodenectomy. A retrospective study of 28 patients

OBJECTIVE

To attempt to reduce the frequency and severity of postoperative anastomotic leakage from pancreaticojejunostomy in patients undergoing pancreatoduodenectomy.

DESIGN

Retrospective case series.

SETTING

Tertiary referral center, department of general surgery, in the 31-month period between April 1, 1993, and November 30, 1995.

PATIENTS AND INTERVENTION

Twenty-eight patients underwent pancreatoduodenectomy with pancreaticogastrostomy. Indications for surgery included carcinoma of the pancreas (n = 14), carcinoma of the ampulla of Vater (n = 8), distal cholangiocarcinoma (n = 3), duodenal carcinoma (n = 1), an islet cell tumor (n = 1), and cystadenoma of the pancreas (n = 1). The median patient age was 62 years (range, 34-76 years). The median duration of surgery was 6.75 hours (range, 4-12 hours).

MAIN OUTCOME MEASURES

An anastomotic leak was defined as a recovery of more than 50 mL/d of amylase-rich fluid from the drains (> 3 times the normal plasma levels) on or after the seventh postoperative day.

RESULTS

An anastomotic leak that lasted between 7 and 14 days developed in 4 patients (14.3%). A pancreatic leak led to no major morbidity. In all cases, leakage was treated by temporary restriction of oral intake and nasogastric drainage. An intra-abdominal collection did not develop in any of these 4 patients. No patient required another surgical procedure for a pancreatic fistula or abdominal collection. One patient (3.6%) died postoperatively. The median duration of the postoperative hospital stay was 20 days (range, 12-43 days), and all patients were discharged from the hospital after restoration of normal oral feeding.

CONCLUSIONS

Pancreaticogastrostomy is a safe method for reconstruction of the pancreatic remnant after pancreatoduodenectomy for periampullary tumors. It results in an acceptable incidence of anastomotic leakage that is easily controlled by conservative measures.

Conservative treatment of a traumatic tear of the left hepatic duct: case report

Injury to the extra-hepatic biliary system in blunt abdominal trauma is rare and difficult to diagnose. In adults, all reported cases were treated surgically. We report a case of a traumatic tear of the left hepatic duct that was treated successfully by endoscopic retrograde cholangiopancreatography and stenting.

Metastatic adenocarcinoma in a thyroid colloid nodule: a rare presentation of colon cancer

Colorectal cancer can remain asymptomatic for years. Frequently symptoms develop insidiously and may often remain unnoticed for long periods, even in the presence of disseminated disease. We herein report an unusual case of a patient with carcinoma of the sigmoid colon and multiple liver metastases. The diagnosis was established only after the patient was operated on for a large colloid nodule, a single microscopic metastatic focus being noticed in the histologic sections. The differential diagnosis compared with the columnar type of papillary carcinoma is discussed.

Malignant neuroepithelioma of the colon

A rare case of malignant peripheral neuroepithelioma originating from the right colon is presented. The patient underwent right hemicolectomy followed by combination chemotherapy and there has been no evidence of tumour recurrence or metastases during three years of follow up. Emphasis is given to the extremely unusual location of this tumour and the favorable clinical outcome.