What is the optimal management of an intra-operative air leak in a colorectal anastomosis?

AIM

An airtight anastomosis on intra-operative leak testing has been previously demonstrated to be associated with a lower risk of clinically significant postoperative anastomotic leak following left-sided colorectal anastomosis. However, to date, there is no consistently agreed upon method for management of an intra-operative anastomotic leak. Therefore, we powered a noninferiority study to determine whether suture repair alone was an appropriate strategy for the management of an intra-operative air leak.

METHOD

This is a retrospective cohort analysis of prospectively collected data from a tertiary care referral centre. We included all consecutive patients with left-sided colorectal or ileorectal anastomoses and evidence of air leak during intra-operative leak testing. Patients were excluded if proximal diversion was planned preoperatively, a pre-existing proximal diversion was present at the time of surgery or an anastomosis was ultimately unable to be completed. The primary outcome measure was clinically significant anastomotic leak, as defined by the Surgical Infection Study Group at 30 days.

RESULTS

From a sample of 2360 patients, 119 had an intra-operative air leak during leak testing. Sixty-eight patients underwent suture repair alone and 51 underwent proximal diversion or anastomotic reconstruction. The clinically significant leak rate was 9% (6/68; 95% CI: 2-15%) in the suture repair alone arm and 0% (0/51) in the diversion or reconstruction arm.

CONCLUSION

Suture repair alone does not meet the criteria for noninferiority for the management of intra-operative air leak during left-sided colorectal anastomosis. Further repair of intra-operative air leak by suture repair alone should be reconsidered given these findings.

How often do patients return to the operating room after colorectal resections?

AIM

We sought to identify the rate of re-operation after an index colorectal surgical procedure and potential contributing risk factors.

METHOD

This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008.

RESULTS

From a total cohort of 635, 265 patients included in the National Surgical Quality Improvement Program over the 4-year study period, we identified 54, 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P < 0.001). The multivariate model identified patients with postoperative diagnostic codes for abdominal cavity hernia or colostomy complication as having the highest odds of return to the operating room within 30 days. Patients returning to the operating room had longer length of stay and higher overall mortality compared with those patients who did not return to the operating room.

CONCLUSION

Return to the operating room is a relatively common occurrence after colorectal resections, with an associated high rate of mortality. Given the association between return to the operating room and adverse patient outcomes, emphasis should be placed on determining strategies to reduce the need for return to the operating room.

Hand-assisted laparoscopic colorectal surgery: an evidence-based review

Despite its increasing use by practitioners, laparoscopic colorectal surgery remains technically challenging. Hand-assisted laparoscopic colorectal surgery may represent a viable hybrid alternative approach to standard laparoscopy. Although few high-quality studies have been carried out, hand-assistance appears to reduce operative time when compared to straight laparoscopy for both left-sided segmental colonic and total colorectal resections. Moreover, hand-assistance appears to maintain the short-term benefits of laparoscopy, while affording the surgeon with the ability to carry out complex cases in a minimally invasive fashion. Data pertaining to the use of hand-assistance for rectal cancer surgery are currently lacking. One the whole, hand-assisted laparoscopic colorectal surgery appears to be a useful tool for the minimally invasive surgeon, one that is perhaps best thought of as an adjunct to simple laparoscopy.

Vascular pedicle ligation techniques during laparoscopic colectomy

BACKGROUND

A variety of devices are available for pedicle ligation during laparoscopic colectomy including vascular staplers, clips, and electrothermal bipolar vessel-sealing devices. This study assesses their speed, reliability, and cost to guide surgeons in their choice for intracorporeal pedicle ligation.

METHODS

A prospective randomized study comparing laparoscopic vascular staplers and disposable clip appliers (S/C) with the LigaSure Atlas (LIG) was performed during elective right, left, and total colectomy. Cases were stratified by procedure. Failure was defined as any bleeding after proper pedicle ligation.

RESULTS

The study included 48 S/C patients and 52 LIG patients with no differences in demographics, diagnosis, procedure, number of vessels ligated per procedure, or operative time. Failure occurred for 14 (9.2%) of the 152 vessels ligated in the S/C group, as compared with 5 (3%) of the 169 vessels ligated in the LIG group (p = 0.02). The median blood loss associated with device failure was 50 ml (range, 20-50 ml) in S/C group, as compared with 100 ml (range 25-800 ml) in the LIG group (p = 0.054). Major blood loss attributable to device failure and surgeon error occurred in only one LIG case. The mean cost per case of vessel ligation was significantly less in the LIG group (317 dollars +/- 0 dollars vs 400 dollars +/- 112 dollars; p < 0.001). The cost differences were greatest for total colectomy (LIG = 317 dollars +/- 0 dollars vs S/C = 565 dollars +/- 67 dollars; p = 0.002).

CONCLUSION

Device failure, although more common in the S/C group, does not result in significant blood loss. The LigaSure Atlas is more cost effective during laparoscopic colectomy, especially total colectomy, and may allow the surgeon more versatility in its application.

Capsule endoscopy findings in celiac disease associated enteropathy-type intestinal T-cell lymphoma

Capsule endoscopy is a new technology developed to investigate diseases of the small intestine. It has been shown to be superior to current modalities such as small-bowel radiography and enteroscopy. We describe a patient with long-standing celiac disease who presented with abdominal pain, diarrhea, and weight loss, after many years on a gluten-free diet. The symptom complex and results from small-bowel radiography and computerized tomography raised concern about progression to lymphoma, and ultimately a laparoscopy and small-bowel resection were done for diagnosis. A capsule endoscopy was performed to assess the extent of the patient's enteropathy-type intestinal T-cell lymphoma after three cycles of chemotherapy. We report the first use of capsule endoscopy in the setting of celiac disease associated enteropathy-type intestinal T-cell lymphoma. These endoscopic findings are correlated with those from gross and microscopic pathology and barium small-bowel radiography.

Hand-assisted laparoscopic sigmoid colectomy: helping hand or hindrance?

BACKGROUND

Hand-assisted laparoscopic colectomy has been introduced as an alternative to the standard laparoscopic technique, but it has not yet been established whether it offers the same benefits. Therefore, we compared the outcome of patients undergoing hand-assisted laparoscopic sigmoid resection (HALSR) to that of those undergoing laparoscopic sigmoid resection (LSR).

METHODS

The study population comprised a sequential series of consecutive patients undergoing elective laparoscopic sigmoid/left colectomy. Values are reported as mean (range).

RESULTS

There were 85 LSR patients and 66 HALSR patients, with no differences in patient demographics or diagnoses. There were slight differences in operative time favoring HALSR (LSR 205 min (90-380) vs HALSR 189 min (120-290); p = 0.07), and the extraction incision was larger in the HALSR group (LSR 6.2 cm (3-25) vs HALSR 8.1 cm (7-12); p < 0.01). There was no difference in time for return of bowel function (LSR 2.8 days (1-15) vs HALSR 2.5 days (1-8); p = 0.31) or length of hospital stay (LSR 5.0 days (2-17) vs HALSR 5.2 days (3-22); p = 0.73). Complications were similar in the two groups (LSR 23% vs HALSR 21%), but there were fewer conversions in the hand-assisted group (HALSR 0% vs LSR 13%; p < 0.01).

CONCLUSIONS

Hand-assisted laparoscopic sigmoid resection yields the same outcomes as standard laparoscopic techniques, but with fewer conversions. Hand-assistance is a helpful innovation that may expand the application of laparoscopic colectomy.

[Laparoscopic restorative proctocolectomy in ulcerative colitis and colonic polyps]

With increasing experience, laparoscopic techniques have been applied even to extended colorectal operations as restorative proctocolectomy in ulcerative colitis and familial adenomatous polyposis. After initial medial transection of the three main vascular pedicles, the colon is dissected free laterally, from the sigmoid orally towards the ileum. The rectum is mobilized down to the pelvic floor. Over a Pfannenstiel incision, the bowel is extracted and the pouch is created. The anastomosis is completed in double-stapling technique. At two departments, 27 patients have been operated on. The median time of operation was 320 min (180-540). The median length of hospital stay was 8.1 days. There was no postoperative mortality. The complication rate was similar to conventional surgery at the same institutions. Three patients had to be re-operated on, two for ileal obstruction close to the pouch, one patient for bleeding from the pouch. In restorative proctocolectomy, laparoscopic techniques prove to be safely feasible. They have the potential to become an appealing alternative to open surgery.

Laparoscopic total colectomy for acute colitis: a case-control study

INTRODUCTION

There are no previous comparative studies of total abdominal colectomy by laparoscopic methods in ulcerative colitis and Crohn's disease patients requiring urgent colectomy. This study aimed to determine the safety and efficacy of laparoscopic colectomy in these patients compared with those undergoing conventional urgent colectomy.

METHODS

Patients undergoing laparoscopic total colectomy for acute colitis were identified in a prospective registry. All patients underwent a total colectomy with creation of an end ileostomy and buried mucous fistula. No patient had fulminant disease (tachycardia, fever, marked leukocytosis, peritonitis), but all were failing to respond to medical treatment. Patients undergoing conventional total colectomy were matched for age, gender, body mass index, diagnosis, disease severity, and operative period. Median values (range) are listed.

RESULTS

From 1997 to 1999, there were 19 laparoscopic and 29 matched conventional patients. There were no inadvertent colotomies or conversions in the laparoscopic group. Although there was no difference in operative blood loss in the laparoscopic group (100 (range, 50-700) ml) when compared with the conventional group (150 (range, 50-500) ml), the operative times were significantly longer in the laparoscopic group (210 (range, 150-270) vs. 120 (range, 60-180) minutes, P < 0.001). Bowel function returned more quickly in the laparoscopic group (1 (range, 1-3) vs. 2 (range, 1-4) days; P = 0.003) and the length of stay was shorter (4 (range, 3-13) vs. 6 (range, 4-24) days; P = 0.04). Complications occurred in three (16 percent) laparoscopic patients (2 wound infection and 1 ileus) and in seven (24 percent) conventional patients (3 wound infection, 3 deep venous thrombosis, 1 upper gastrointestinal bleed).

CONCLUSIONS

Laparoscopic total colectomy is feasible and safe in patients with acute nonfulminant colitis and may lead to a faster recovery than conventional resection.

CO2 pneumoperitoneum does not enhance tumor growth and metastasis: study of a rat cecal wall inoculation model

INTRODUCTION

Although many studies have evaluated the effects of carbon dioxide pneumoperitoneum on port site recurrence, little is known about its outcome on tumor growth and metastasis. The effect of pneumoperitoneum with carbon dioxide on cecal tumor growth and metastasis was compared with laparotomy using a rat colon cancer cell line.

METHODS

Time Course Study: Fifty WF/BN F1 hybrid rats were inoculated with 2,000,000 WB2054M5 tumor cells into the cecal wall and explored two to ten weeks after injection. Main Study: 152 rats were randomly assigned either to 6-mmHg CO2 pneumoperitoneum (30 minutes) or 4-cm laparotomy (30 minutes) two weeks after tumor inoculation and were explored four weeks after treatment.

RESULTS

Time Course Study: Thirty-seven (95 percent) of the surviving rats developed a cecal wall tumor, and there was progressive tumor growth and metastasis over the ten-week period. At six weeks, metastasis occurred to the liver in 25 percent, to the lung in 38 percent, and to the lymph node in 63 percent, and peritoneal seeding occurred in 38 percent; this time period was chosen for the main study. Main Study: At the time of treatment (2 weeks), 124 rats were eligible for randomization. One hundred two rats survived the six-week period (50 pneumoperitoneum, 52 laparotomy) and were killed. There were no differences between the CO2 pneumoperitoneum and laparotomy groups regarding cecal tumor growth (1.043 vs. 0.894 g) and metastases to the liver (32 vs. 37 percent), lung (34 vs. 17 percent), lymph node (84 vs. 77 percent), and wound or port (20 vs. 23 percent).

CONCLUSIONS

A cecal wall inoculation model mimics the natural cascade of colon cancer growth and metastasis. CO2 pneumoperitoneum did not affect the tumor growth and metastasis to the liver and other organs when compared with laparotomy in this model.

Long-term outcomes of the ileal pouch anal anastomosis: the association of bowel function and quality of life 5 years after surgery

INTRODUCTION

Previous studies have reported that mean health related quality of life (HRQL) levels generally attain normalcy following construction of an ileal pouch anal anastomosis (IPAA). It appears inconsistent, however, that these normal HRQL levels are achieved while bowel function (BF) scores generally remain statistically worse than "normal" (e.g., 4-8 stools/day, possible anal leakage, diaper usage). To investigate this inconsistency, the current study attempts to determine if any statistical associations are present between HRQL and BF, specifically in the long term. Multivariate regression analyses are performed using each of 8 individual HRQL domains against the full model of BF characteristics.

METHODS

All patients more than 5 years status post an ileal pouch anal anastomosis (IPAA) procedure for familial adenomatous polyposis (FAP) at a single institution were studied. FAP was chosen because patients are routinely asymptomatic preoperatively. BF (e.g., stool frequency, anal leakage) and HRQL (using the 8 health domains of the SF-36) were assessed by patient interview. Student's t tests and full model multivariate regression analyses were used to analyze associations between BF and HRQL.

RESULTS

The sample included 25 patients (14 male). Mean age was 39 years, mean follow-up time was 11 years. Although mean scores for the 8 individual HRQL domains were not statistically different from the general United States population, regression analyses of the different domains did demonstrate significant associations with varying levels of BF. While controlling for age and gender, the analyses show that the physical function domain is improved with the ability to pass flatus independent of stool, and physical role and mental health domains are improved with decreased stool frequency. The social function domain is improved with increased stool retention time, while the perception of general health is improved with less diaper usage and less sexual dysfunction.

CONCLUSIONS

This study shows that a statistically significant association between HRQL levels and BF is present. Of the numerous BF characteristics tested, five appear to be of greater importance with regard to certain HRQL domains. This finding may have clinical implications concerning pouch construction and surgical technique. Methodologically, this study demonstrates that merely using mean levels to describe HRQL may not elucidate meaningful relationships between important clinical outcomes, such as function and HRQL.

Laparoscopic restorative proctocolectomy: case-matched comparative study with open restorative proctocolectomy

PURPOSE

A laparoscopic approach to restorative proctocolectomy is new and has not been compared recently with the traditional open procedure. By using prospectively gathered data, laparoscopic and open restorative proctocolectomy procedures in mucosal ulcerative colitis and familial adenomatous polyposis patients were compared by using a case-matched design.

METHODS

Forty patients, composing 20 consecutive laparoscopic cases (13 mucosal ulcerative colitis, 7 familial adenomatous polyposis), were matched for age, gender, and body mass index with 20 open cases (13 mucosal ulcerative colitis, 7 familial adenomatous polyposis) performed during the same time period. Mucosal ulcerative colitis patients were also matched for severity of disease by using hemoglobin and albumin levels, whole blood count, and steroid dependency. A loop ileostomy was made in 12 of 13 laparoscopic mucosal ulcerative colitis patients, all open mucosal ulcerative colitis patients, and no familial adenomatous polyposis patients.

RESULTS

The median age was 25 (range, 9-61) years. There were no intraoperative complications in either group and no conversions in the laparoscopic group. The operative times (median, range) were significantly longer in laparoscopic cases (330, 180-480 minutes) vs. open cases (230, 180-300 minutes), P < 0.001. Bowel function returned more quickly in laparoscopic cases (2, 1-8 days) vs. open cases (4, 1-13 days), P = 0.03; and the length of stay was shorter in laparoscopic cases (7, 4-14 days) vs. open cases (8, 6-17 days), P = 0.02. For diverted patients, the median length of stay was reduced by two days in laparoscopic cases (6, 4-14 days) vs. open cases (8, 6-17 days), P = 0.01. Complications occurred in 4 of 20 laparoscopic patients (3 obstruction/ileus and 1 pelvic abscess) and 5 of 20 open patients (2 obstruction and ileus, 1 each anastomotic leak and abscess, peptic ulceration, and episode of dehydration).

CONCLUSIONS

Return of intestinal function and length of stay are reduced in the laparoscopic group compared with open group. A laparoscopic approach to restorative proctocolectomy has the potential of becoming an appealing alternative to conventional restorative proctocolectomy surgery.

Laparoscopic enterocystoplasty

OBJECTIVES

To report the initial clinical experience with laparoscopic augmentation enterocystoplasty using the ileum, sigmoid, or right colon.

METHODS

Three patients with functionally reduced bladder capacities due to neurogenic causes underwent laparoscopic enterocystoplasty: ileocystoplasty (n = 1), sigmoidocystoplasty (n = 1), and cystoplasty with cecum and proximal ascending colon (n = 1). In the last patient, a continent, catheterizable, ileal conduit with an umbilical stoma was also created. In all patients, bowel reanastomosis was performed by exteriorizing the bowel loop outside the abdomen through a 2-cm extension of the umbilical port site. Creation of a large cystotomy, mobilization of the appropriate bowel segment, and the circumferential enterovesical anastomosis were all performed intracorporeally by laparoscopic techniques.

RESULTS

The operative times were 5.3, 8, and 7 hours. All three laparoscopic enterovesical anastomoses were watertight, without postoperative urinary extravasation. The hospital stay was 7, 5, and 4 days.

CONCLUSIONS

Laparoscopic enterocystoplasty is feasible, safe, and efficacious and appears to be an attractive alternative to open enterocystoplasty. Various bowel segments can be used as with open surgery, including creation of a continent, catheterizable stoma. Although further technical refinements will undoubtedly occur, even at this early stage, it is clear that the technical steps of an enterocystoplasty can be satisfactorily and effectively performed laparoscopically.

Laparoscopic surgery of the colon and rectum

The use of laparoscopic techniques in benign colorectal surgery has expanded over the past several years, but controversy continues to surround the use of laparoscopic resection in cases of colorectal carcinoma. Diagnostic laparoscopy, the creation of stomas, and limited resections are becoming reasonable indications for benign diseases. In cases of malignancy, resection through a conventional incision or a laparoscope must adhere to the same defined surgical oncologic principles. Current randomized trials comparing open resection to laparoscopic resection should address these concerns. Port-site recurrence remains a leading concern regarding the widespread acceptance of laparoscopic resection for colorectal carcinoma. This article focuses on the applications of laparoscopic colorectal surgery for malignant diseases. Further research in this area combined with advances in laparoscopic technology will be critical to the future successful application of laparoscopic surgery to colorectal carcinoma.

Functional results after perineal complications of ileal pouch-anal anastomosis

PURPOSE

This study investigated the functional significance of perineal complications after ileal pouch-anal anastomosis.

METHODS

Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi-squared and Fisher's exact probability tests.

RESULTS

Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications.

CONCLUSIONS

An appreciable number of perineal complications occur after ileal pouch-anal anastomosis. Pouch-perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch-anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.

Fatigue rate index as a new measurement of external sphincter function

PURPOSE

Assessment of sustained voluntary contraction of the external sphincter is helpful in evaluating the patient who has a defecation disorder on presentation. A new index of external sphincter function is described.

METHOD

A prospective registry of patients referred for computerized anal manometry using standard protocols was reviewed. Patients were grouped by primary symptoms; those with overlapping complaints were excluded. The rate of fatigue, defined as the change in stationary squeeze over a 40-second period of voluntary contraction, was calculated by linear regression analysis. Fatigue rate index, a calculated measure of time necessary for the external sphincter to become completely fatigued, was determined to permit comparison of external sphincter fatigue in patients with different complaints.

RESULTS

Twenty-six healthy volunteers (15 women; mean age, 45 years), 33 patients with a primary complaint of anal seepage (13 women; mean age, 53 years), 75 patients with gross incontinence (61 women; mean age, 53 years), and 49 patients with severe constipation (41 women; mean age, 45 years) were evaluated. Mean resting and squeeze pressures were 55 mmHg and 107 mmHg for volunteers, 37 mmHg and 97 mmHg for patients with seepage, 30 mmHg and 49 mmHg for incontinent patients, and 56 mmHg and 93 mmHg for constipated patients. Pudendal neuropathy, as evidenced by a prolonged pudendal nerve terminal motor latency (> 2.4 ms), was identified in 13 percent of volunteers, 32 percent of patients with seepage, 54 percent of incontinent patients, and 38 percent of constipated patients. Mean fatigue rate index was 3.3 minutes for volunteers, 2.3 minutes for seepage patients, 1.5 minutes for incontinent patients, and 2.8 minutes for constipated patients. Compared with volunteers and patients with seepage, the incontinent patients had a significantly shorter fatigue rate index (P < 0.05; Student's t-test), which was independent of the variations in resting pressure (P < 0.05; two-way analysis of variance).

CONCLUSION

The external anal sphincter is normally subject to fatigue. Patients with worsening degrees of incontinence have a predictably lower fatigue rate index. Fatigue rate index is a simple measure of external sphincter integrity, which may be used in assessment of sphincter function and future treatment protocols.

Afferent limb obstruction complicating ileal pouch-anal anastomosis

PURPOSE

Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb at the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy.

METHODS

Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database of all patients who have undergone IPAA since 1980. Records of patients who were identified as having afferent limb obstruction as a cause of bowel obstruction after IPAA were reviewed.

RESULTS

A total of 567 patients had undergone total proctocolectomy and ileoanal J-pouch at time of the study. Of 122 patients with one or more episodes of obstruction after IPAA, 48 required operative intervention. Afferent limb obstruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruction (4 of 6 patients). Contrast small-bowel series and enemas were suggestive of obstruction in four of six patients, the most consistent radiographic finding being small-bowel dilation to the level of the pouch inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterior to the pouch, causing acute angulation at the pouch inlet. Rather than risk injury to the pouch or its mesentery, the obstruction was bypassed by side-to-side anastomosis of the afferent limb to the pouch (enteroenterostomy) in five of six patients. One patient underwent ileostomy only because of technical considerations. Two patients required re-exploration and pexy of the afferent limb to the pelvic sidewall (pouchopexy) to relieve recurrent afferent limb obstruction.

CONCLUSION

Afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from distal ileum to the pouch is safe and effective treatment. Because of the risk of recurrent afferent limb angulation, concurrent pouchopexy should be considered.

Evolutionary changes in the pathologic diagnosis after the ileoanal pouch procedure

PURPOSE

Inadequate initial differentiation between ulcerative colitis and Crohn's disease may lead to a diagnosis of indeterminate colitis. Construction of an ileoanal pouch in these patients may result in significant morbidity and pouch failure when the ultimate diagnosis is Crohn's disease.

METHOD

We prospectively studied 543 patients with idiopathic inflammatory bowel disease to determine whether a patient's pathologic diagnosis changed with time and how it affected outcome.

RESULTS

Preoperative diagnosis was ulcerative colitis in 499 patients, indeterminate colitis in 42 patients, and Crohn's disease in 2 patients. Prior colectomy was performed in 58 percent of patients with ulcerative colitis and in all patients with indeterminate colitis and Crohn's disease. Postoperatively, the diagnosis changed in 20 patients with ulcerative colitis (13 to indeterminate colitis, 7 to Crohn's disease). Another two patients with indeterminate colitis showed evidence of Crohn's disease in the resected rectal specimen. As patients were followed up, an additional 13 patients were found to have Crohn's disease (5 indeterminate colitis, 8 ulcerative colitis). With the current diagnosis, perineal complications and pouch failure occurred, respectively, in 23 and in 2 percent of patients with ulcerative colitis, in 44 and in 12 percent of patients with indeterminate colitis, and in 63 and in 37 percent of patients with Crohn's disease. Pathologic diagnosis was altered in 35 patients (6 percent) overall, with a 12-fold increase in the diagnosis of Crohn's disease. Only 3 percent of patients with ulcerative colitis compared with 13 percent of patients with indeterminate colitis had a change in diagnosis to Crohn's disease (P = 0.006; Fisher's exact test).

CONCLUSION

Pouch-related complications, eventual pouch failure, and discovery of underlying Crohn's disease occurred in a significant number of patients with a diagnosis of indeterminate colitis. Until more accurate diagnostic differentiation is available, caution is advised in recommending the ileoanal pouch procedure to patients with indeterminate colitis.

Gastroduodenal polyps in familial adenomatous polyposis

BACKGROUND

Malignant degeneration of gastroduodenal polyps has been noted in patients with familial adenomatous polyposis. To evaluate this problem further, patients with familial adenomatous polyposis were contacted and offered upper gastrointestinal tract endoscopy.

METHODS

A prospective endoscopic examination was performed in 42 patients.

RESULTS

The median age of patients at endoscopy was 35 years. The duration of known familial adenomatous polyposis at the time of endoscopy was 8 years. Polyps were visualized in 21 patients (50%). Gastric polyps were seen in 14 patients (33%), duodenal polyps were seen in 11 patients (26%), and ampullary polyps were seen in 7 patients (17%). Nine patients (43%) had polyps in more than one site. Adenomatous change was noted in 73% of duodenal lesions and in only 14% of gastric polyps. Surgical intervention was required in four patients; one patient had an early ampullary carcinoma, and three patients had severe dysplasia involving the duodenum or ampulla. All four patients had undergone a previous screening examination, results of which were normal in three patients. Compared with other patients, these four patients were older (median age, 58 years; p = 0.02) and had a longer duration of disease (median duration, 25 years; p = 0.002).

CONCLUSIONS

All patients with familial adenomatous polyposis require lifelong endoscopic surveillance to detect malignant degeneration, which may appear later in life.

"Routine" preoperative studies. Which studies in which patients?

The utility of mass screening of preoperative patients has never been demonstrated for the majority of tests. Although screening patients to uncover occult disease appears logical, in reality it has resulted in excessive expenditure of our health care dollars with limited benefit. More than $30 billion is spent annually on preoperative examinations, 60% of which are unnecessary. In addition, iatrogenic injury has resulted from the further evaluation and treatment of false-positive results. A selective utilization of routine examinations can accurately supplement the clinician's evaluation, providing the patient with a complete preoperative assessment. The benefits of selective testing must be balanced against the possible omission of warranted examinations, highlighting the need for a more reliable system for test ordering.

Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of subsequent pouch salvage

PURPOSE

The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion.

METHODS

Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records.

RESULTS

Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs. 43 percent; P < 0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs. 3.4 percent; P < 0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis (P < 0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease.

CONCLUSIONS

The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.

Obstruction after ileal pouch-anal anastomosis: a preventable complication?

Small bowel obstruction is a common complication after ileal pouch-anal anastomosis. This review of 460 patients examines the frequency of small bowel obstruction and determines potential risk factors. The leading indication for ileal pouch-anal anastomosis was ulcerative colitis (83 percent). In 142 patients (31 percent), loop ileostomy was rotated 180 degrees to facilitate emptying of the ileostomy. Ninety-four patients (20 percent) had 109 episodes of obstruction. Obstruction occurred after creation of the pouch (40 episodes), closure of the ileostomy (29 episodes), or developed during the subsequent follow-up period (40 episodes). Operative intervention was required in 39 percent of the episodes (7 percent of all patients). At operation, the most common point of obstruction was at closure of the ileostomy (n = 22/42, 52 percent). In 16 of these patients, the ileostomy had been rotated. Multiple risk factors, including age, sex, primary diagnosis, surgeon incidence, pouch type, prior colectomy, steroid usage, stomal rotation, technique of closure of the ileostomy, and prior obstruction, were examined by univariate and multivariate analysis. Of all factors, only stomal rotation was statistically significant (P = 0.0005, chi-squared analysis). Rotation of the loop ileostomy during ileal pouch-anal anastomosis, although an apparent technical refinement, is unnecessary and predisposes to obstruction.

Long-term results of the ileoanal pouch procedure

Many surgeons consider the ileoanal pouch procedure to be the procedure of choice for patients who require surgery for ulcerative colitis and familial adenomatous polyposis. To determine long-term results, 460 patients (mean +/- SD age, 31 +/- 9 years) who underwent the ileoanal pouch procedure from 1980 through 1991 were prospectively observed by computerized registry. The leading indication for operation was ulcerative colitis (n = 382; 83%). A J-shaped reservoir was created in 434 patients (94%). More than 5 years after ileostomy closure, the mean number of bowel movements was 5.8 +/- 2.2, and 13% of patients had leakage. Most patients (94%) were satisfied with their results. Sixteen patients (3.5%) required recreation of a permanent stoma for pouch failure. Complications (major and minor) occurred in 266 patients (58%) and included obstruction (n = 94; 20%), pouch fistula (n = 26; 6%), anastomotic stricture (n = 40; 9%), anastomosis separation (n = 14; 3%), and pouchitis (n = 83; 18%). Modifications in technique and increased operative experience have significantly decreased the incidence of obstruction (P = .05) and pouch-related complications (P = .004). Despite complications, long-term results are acceptable, and patient satisfaction remains high.