Surgical outcomes in steroid refractory acute severe ulcerative colitis: the impact of rescue therapy

AIM

The advent of rescue medical therapy (cyclosporin or infliximab) and laparoscopic surgery has shifted the paradigm in managing steroid refractory acute severe ulcerative colitis (ASUC). We investigated prospectively the impact of rescue therapy on timing and postoperative complications of urgent colectomy and subsequent restorative surgery for steroid refractory ASUC.

METHOD

All consecutive presentations of steroid refractory ASUC at the Royal Brisbane Hospital (1996-2009) were entered in the study. Data collated included demographics, clinical and laboratory parameters on admission, medical therapy and operative and postoperative details. Steroid refractory ASUC patients undergoing immediate colectomy were compared with those failing rescue therapy and requiring same admission colectomy.

RESULTS

Of 108 steroid refractory ASUC presentations, 19 (18%) received intravenous steroids only and proceeded directly to colectomy. Rescue medical therapy was instituted in 89 (82%) patients with 30 (34%) failing to respond and proceeding to colectomy. There was no significant difference in the median time from admission to colectomy for rescue therapy compared with steroid-only cases (12 vs 10 days, P = 0.70) or 30-day complication rates (27%vs 47%, P = 0.22). The interval from colectomy to a subsequent restorative procedure was significantly longer for patients who failed rescue therapy (12 vs 5 months, P = 0.02). Furthermore 30-day complications following pouch surgery were significantly higher in patients who failed rescue therapy (32%vs 0%, P = 0.01).

CONCLUSION

Rescue therapy in steroid refractory ASUC is not related to delay in urgent colectomy or increased post-colectomy complications.

Laparoscopic resection of advanced colorectal cancer

Background

Palliative resection of the primary tumour in asymptomatic patients with stage IV colorectal cancer is associated with improved survival and fewer complications. Laparoscopic surgery is widely employed in the curative treatment of colorectal cancer, but its value in advanced colorectal cancer remains unclear.

Methods

All patients who underwent laparoscopic resection of primary colorectal cancer in this unit between June 1991 and Jan 2010 were entered into a prospective computerized database. Outcomes for patients with laparoscopic resection of stage IV colorectal cancer were compared with those of patients who had laparoscopic surgery for stage I disease.

Results

Some 185 patients with stage IV colorectal cancer who underwent laparoscopic resection were compared with 310 patients who had stage I colorectal cancer. Some 94·1 and 98·4 per cent of operations respectively were completed laparoscopically. Hospital stay was slightly longer in the group with stage IV disease (mean 6·2 versus 5·3 days; P = 0·091). The 30-day mortality rate was 2·7 per cent in patients with stage IV disease and 0·6 per cent in those with stage I tumours (P = 0·061). There was no difference in complications. One-year survival rates were 77·8 and 99·0 per cent respectively (P < 0·001).

Conclusion

Short-term outcomes after laparoscopic surgery for stage IV colorectal cancer in selected patients are equivalent to those for stage I cancers.

Preservation of sexual and bladder function after laparoscopic rectal surgery

BACKGROUND

There have recently been reports of higher levels of bladder and sexual dysfunction in men after laparoscopic rectal surgery when compared with those undergoing open surgery. This has led some surgeons to question the role of the laparoscopic approach to rectal surgery.

METHOD

This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2406 patients undergoing laparoscopic colorectal surgery. Bladder function, potency and ejaculation were assessed at postoperative clinic visits for men undergoing laparoscopic low or ultra-low anterior resection and abdominoperineal excision of the rectum.

RESULTS

A total of 101 males were identified (median age 62 years: range 20-90 years). Urinary dysfunction was reported by six (6%) patients. Six (6%) patients had sexual dysfunction, manifesting as retrograde ejaculation in four patients and erectile dysfunction in a further two patients.

CONCLUSIONS

The low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced, dedicated laparoscopic colorectal surgeons. Laparoscopic restorative surgery for rectal cancer has been performed here only since 2001 after considerable experience accrued in operating on benign rectal disease and colon cancer. Studies from elsewhere reporting poorer functional outcomes have probably included a significant number of patients on the surgeons''learning curve'.

Hypothermia in open and laparoscopic colorectal surgery

PURPOSE

Perioperative hypothermia has been shown to be an important determinant of outcome after open colorectal resections. The degree of hypothermia occurring with laparoscopic-assisted colorectal surgery is, however, unknown, and the effectiveness of standard warming measures is untested. This study was designed to assess hypothermia in open and laparoscopic-assisted colonic resections using a standardized warming protocol.

METHODS

A prospective, nonrandomized study was performed with temperature measurements recorded every ten minutes. Statistical analysis was based on repeated measures analysis of variance models with significance set at the conventional 95 percent (two tailed).

RESULTS

A total of 107 patients were entered into the trial; 68 had open and 39 had laparoscopic colectomies. The groups were well matched for age, weight, and duration of surgery, with a median operating time of 180 minutes in each group. The average drop in temperature from commencement of surgery to lowest point was 0.68 degrees C (standard deviation, 0.08) in the open group, compared with 0.53 degrees C (standard deviation, 0.06) in the laparoscopic group (P = 0.126).

CONCLUSIONS

Laparoscopic-assisted colorectal surgery is not associated with a higher incidence of perioperative hypothermia than open colorectal surgery using a standard warming regimen for both groups. On the basis of these results, standard temperature conservation is adequate, even for long, complex laparoscopic procedures.

Laparoscopically assisted colorectal surgery in the elderly

INTRODUCTION

Open colorectal surgery in elderly patients is associated with increased morbidity and mortality rates compared with those in younger age groups. It also requires more intensive postoperative support, longer hospitalization, and in many cases leads to prolonged rehabilitation or institutionalization. Because of its less invasive nature, laparoscopically assisted colorectal surgery may lead to a reduced period of convalescence. However, the safety of advanced laparoscopic surgical techniques in the elderly has not been established, so this prospective comparative study was undertaken.

METHODS

All patients aged 80 years or more who were undergoing an elective laparoscopic or open colorectal procedure between 1 January 1992 and 30 June 1997 were assessed prospectively. Patients having simple stoma formation were excluded. Perioperative care, operative results and subsequent function were analysed.

RESULTS

There were 42 patients in the laparoscopic group and 35 in the open group, with a median age of 84 years in each group. Five patients undergoing laparoscopic surgery required conversion to an open procedure. No complications related to laparoscopy occurred. Three patients died after operation in the laparoscopic group and four in the open group, with morbidity in seven and 15 patients respectively. Median hospital stay was 9 (range 4-21) days for patients having the laparoscopic operation, and 17 (range 7-28) days in the open cases. At 4 weeks after operation 30 of the 35 independent patients surviving the operation in the laparoscopic group and 16 of 28 in the open group were back to preoperative activity levels.

CONCLUSION

In this series laparoscopically assisted colorectal surgery was safe and was associated with a low incidence of complications, short hospitalization and a rapid return to preoperative activity levels when compared with open colorectal resections in this age group.

Marsupialization of presacral collections with use of an endoscopic stapler

Patients with anastomoses at the anorectal ring, with or without anastomotic dehiscence, may develop large presacral collections. Such collections often drain poorly through the anastomosis, leading to chronic sepsis. A novel method of widely draining such collections by "marsupialization" into the bowel lumen with use of an endoscopic stapler inserted transanally is described.

Laparoscopically assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients

PURPOSE

The objectives of this study were to refine the technique of laparoscopically assisted anterior resection (LAR) for diverticular disease and to analyze the morbidity and mortality rates, and longer term follow-up of the first 100 consecutive patients.

METHODS

Data were collected prospectively, and follow-up was performed by an independent assessor using a standardized questionnaire.

RESULTS

The median duration of surgery was 180 minutes, the median time for passage of flatus was 2 days after surgery, and the median length of hospital stay was 4 days. Overall, the morbidity rate was 21%, and the wound infection rate was 5%. There were no deaths. Eight patients underwent open laparotomy. The rate of complications was significantly greater in the latter group of patients (75%) than in those who underwent laparoscopy (16%, p = 0.002). The comparison between the first 20 cases and the last 20 patients revealed a significantly shorter duration of surgery (median 225 min. vs. 150 min.; p < 0.0001) and decreased length of stay (6 days vs. 4 days, p < 0.0001). Apart from a nonsignificant increase in the length of surgery, there were no differences in other study parameters when comparisons were made between those patients who underwent LAR for complicated diverticular disease and those patients who underwent uncomplicated diverticular disease.

FOLLOW-UP

Ninety patients were available for follow-up at a median time of 37 months. Ninety-three percent of the patients reported that the surgery had improved their symptoms. No patient required hospitalization, and no one was treated with antibiotics for recurrent symptoms.

CONCLUSION

Laparoscopically assisted anterior resection for diverticular disease has acceptable morbidity and mortality rates and a median postoperative hospital stay of only 4 days. Follow-up investigations revealed no recurrence of diverticulitis, and patients reported satisfaction regarding cosmetic and functional results.

Laparoscopic stoma formation for faecal diversion

BACKGROUND

Laparoscopic creation of an intestinal stoma may be preferable to open operation when intervention is required solely for faecal diversion.

METHODS

Experience with laparoscopic intestinal stoma formation for faecal diversion from a single institution is presented.

RESULTS

A total of 55 stomas were studied, 40 laparoscopic and 15 open. The conversion rate from laparoscopic to open operation was 5 per cent. Mean(s.e.m.) operating time was significantly reduced for laparoscopic stomas (54(4.7) versus 72(8.7) min). Time to return of bowel function was significantly reduced (1.6(0.3) versus 2.2(0.2) days). Mean(s.e.m.) hospital stay was significantly reduced in the laparoscopic group (7.4(0.5) versus 12.6(2.5) days).

CONCLUSION

Morbidity and mortality appeared to be reduced in patients undergoing laparoscopic stoma formation. The technique was found to be safe, suitable for the majority of patients and to give results superior to those of open surgery.

Laparoscopic-assisted resection-rectopexy for rectal prolapse: early and medium follow-up

PURPOSE

Objectives of this study were to describe the technique of laparoscopic-assisted resection rectopexy and audit the clinical outcomes, including review of functional results.

METHODS

Data were prospectively collected for duration of operation, time to passage of flatus and feces postoperatively, hospital stay, morbidity, and mortality. Follow-up was performed by an independent assessor using a standardized questionnaire. Patients were also assessed by clinical review or telephone interview.

RESULTS

During a four-year period, 34 patients underwent laparoscopic repair for rectal prolapse, of which 30 patients underwent laparoscopic-assisted resection rectopexy. Median duration of the operations was 185 minutes, median time for passage of flatus was two days postoperatively, and median length of hospital stay was five days. Morbidity was 13 percent and mortality rate was 3 percent. Comparison between the first ten patients who underwent laparoscopic-assisted resection rectopexy and the last ten revealed a significant reduction in both median duration of operating time (224 vs. 163 minutes; P < 0.005) and length of stay (6 vs. 4 days; P < 0.015). Follow-up study conducted at a median time of 18 months revealed that most patients (92 percent) felt that the operation had improved their symptoms, that incontinence was improved in 14 of 20 patients with impaired continence (70 percent), and that constipation was improved in 64 percent. Symptoms of incomplete emptying and the need to strain at stool were both improved in 62 and 59 percent of patients, respectively. No full-thickness recurrences have occurred, but two patients have had mucosal prolapse detected (7 percent) and treated.

CONCLUSION

Laparoscopic-assisted resection rectopexy is feasible and safe, with acceptable recurrence rates and functional results compared with the open procedure in the surgical literature. There is rapid return of intestinal function associated with an early discharge from hospital.

Large intestinal lymphocytic phlebitis and venulitis in chronic ulcerative colitis

Colonic vasculitis is seen in Crohn's disease and as a component of primary systemic vasculitis. It has rarely been described in chronic ulcerative colitis. Here we report a case of ulcerative colitis with prominent transmural lymphocytic phlebitis and venulitis. Although this is, to our knowledge, the first description of such an association, its recognition is important if confusion with other entities is to be avoided. The etiology of the vascular changes is unclear but they may be a secondary phenomenon induced by antigens, toxins or cytokines draining from the inflamed mucosa.

Laparoscopic colorectal surgery--new advances and techniques

Laparoscopic colorectal surgery is being assessed in many centres worldwide. This paper looks at the authors' experiences of 320 laparoscopic colorectal procedures and discusses modifications of technique, new instruments and changes in outcomes as experience is attained. Operating times are now approaching that of open surgery as the "learning curve" levels out. For example, the median operating time for the last 20 patients undergoing a laparoscopic right hemicolectomy was 2.1 hours and anterior resection was 2.2 hours. Of the 320 laparoscopic colorectal procedures performed, the conversion rate of 8.1% (26 patients) and perioperative death rate of 2.2% (7 patients) appear to be acceptable for the extent of surgery performed. The median inpatient stay for the last 20 patients undergoing a laparoscopic-assisted right hemicolectomy or high anterior resection was 5 days (range 3 to 11 days) and 4 days (range 3 to 18 days) respectively. Outcomes for cancer patients are encouraging. Of 106 selected patients having a potentially curative resection for colorectal and anal cancer, there have been 10 recurrences (9.4%) to date. Sixty-four patients have now been followed-up for more than 2 years. It is our belief that with appropriate patient selection a laparoscopic approach can give outcomes similar to open surgery with a slightly decreased hospital stay and convalescence. Laparoscopic colorectal surgery, particularly for benign disease, should be encouraged.

Laparoscopic-assisted colorectal surgery. Lessons learned from 240 consecutive patients

PURPOSE

To audit the development and outcomes of laparoscopic colorectal surgery at the Royal Brisbane Hospital.

METHODS

Since July 1991, laparoscopic-assisted colectomy for benign and malignant colorectal disease has been performed on more than 300 patients at the Royal Brisbane Hospital. This paper summarizes the outcome for the first 240 patients who underwent a laparoscopic colorectal procedure. All laparoscopic data were collected prospectively, and for selected studies, data were compared with open surgical controls.

RESULTS

Nineteen patients required open conversion (7.9 percent). There was a significant decrease in wound infection rates in patients having a laparoscopic-assisted colectomy (3.6 percent) compared with historical controls (7.9 percent) (P < 0.05; chi-squared). There were five anastomotic leaks, five laparotomies for postoperative adhesive obstruction, and four perioperative deaths. A total of 103 patients had a procedure for colorectal cancer. Of the 79 potentially curative procedures, there have been 5 (6.3 percent) recurrences to date.

CONCLUSION

The overall morbidity and mortality in this series seem to be acceptable compared with that of open procedures.

Do the teaching hospitals of the University of Queensland really want a four-year medical course? A guarded yes

OBJECTIVE

To gauge the measure of support among clinical teaching staff for the University of Queensland's proposals to introduce a four-year graduate entry integrated medical curriculum.

SETTING

The three largest teaching hospitals of the University of Queensland Faculty of Medicine.

METHODS

A questionnaire was sent to 565 consultants and 493 junior medical staff regarding deficiencies of the present six-year course, deficiencies in present methods of selecting students, and possible solutions.

RESULTS

154 (68%) full-time consultants, 174 (51%) visiting consultants and 197 (40%) junior staff replied. Ninety per cent of the consultants and 60% of the junior staff were current teachers. Respondents strongly supported the need for major change, the integration of biomedical sciences into clinical teaching and the use of problem-based learning. Regarding selection, over 80% of respondents considered graduate entry to have no advantage over undergraduate entry, but there was strong support for an external examination including sciences. There was also strong support for broadening entry criteria to include common sense, motivation and empathy. Seventy-two per cent of consultants and 82% of juniors opposed the proposals in their present form. However, 52% of consultants (but only 23% of juniors) would support the concept of a four-year integrated course if the issue of selection criteria could be resolved.

CONCLUSION

A majority of consultants support the concept of a four-year integrated curriculum which uses problem-based learning methods. They do not support the proposed selection criteria based upon graduate entry, but would support a predominantly science-based selection process, not necessarily restricted to graduate applicants, but incorporating broader personal characteristics than are used at the present time.

Metastatic carcinoid tumour: stability throughout pregnancy

A patient with asymptomatic histologically proven extensive hepatic metastases of carcinoid tumour had no progression of disease for over 4 years without specific treatment. Throughout a normal pregnancy the hepatic metastases remained stable by clinical, computerized tomography and biochemical criteria.

Crohn's disease and anal carcinoma: an association? A case report and review of the literature

We believe this is the first Australian reported case of anal carcinoma complicating Crohn's disease. The opportunity has been taken to present a detailed case report and review the increasing overseas literature about this problem.

Colonoscopic polypectomy

Seven hundred and forty-one colonic polyps have been removed by colonoscopic polypectomy during 300 examinations. Up to 36 polyps were removed at a single examination. Colonoscopic treatment of villous adenomas to 7 cm has been successfully performed in elderly and infirm patients. There were no deaths or incidents of perforation and the only significant complications were two secondary haemorrhages requiring transfusion. The presence of a polyp was not definitely reported in 40% of barium enema X-ray examinations carried out within three months of polypectomy. Double contrast X-ray examinations were significantly more sensitive in the detection of polyps. Colonoscopic polypectomy is a safe and effective technique. All colonic polyps should be removed by this technique after diagnosis.