Self-assessment quiz: answers, critiques, and references. Diverticulitis.

Dis Colon Rectum. 2012 Apr;55(4):e46-7

Authors:

PMID: 22426279 [PubMed - indexed for MEDLINE]

Measures of outcome in rectal cancer surgery: a work in progress.

Dis Colon Rectum. 2012 Apr;55(4):369-70

Authors: Tilney HS

PMID: 22426258 [PubMed - in process]

Pretreatment high-resolution rectal MRI and treatment response to neoadjuvant chemoradiation.

Dis Colon Rectum. 2012 Apr;55(4):371-7

Authors: Chang GJ, You YN, Park IJ, Kaur H, Hu CY, Rodriguez-Bigas MA, Skibber JM, Ernst RD

Abstract

BACKGROUND: Use of rectal MRI evaluation of patients with rectal cancer for primary tumor staging and for identification for poor prognostic features is increasing. MR imaging permits precise delineation of tumor anatomy and assessment of mesorectal tumor penetration and radial margin risk.

OBJECTIVE: The aim of this study was to evaluate the ability of pretreatment rectal MRI to classify tumor response to neoadjuvant chemoradiation.

DESIGN: This study is a retrospective, consecutive cohort study and central review.

SETTING: This study was conducted at a tertiary academic hospital.

PATIENTS: Sixty-two consecutive patients with locally advanced (stage cII to cIII) rectal cancer who underwent rectal cancer protocol high-resolution MRI before surgery (December 2009 to March 2011) were included.

MAIN OUTCOME MEASURES: The primary outcomes measured were the probability of good (ypT0-2N0) vs poor (≥ypT3N0) response as a function of mesorectal tumor depth, lymph node status, extramural vascular invasion, and grade assessed by uni- and multivariate logistic regression.

RESULTS: Tumor response was good in 25 (40.3%) and poor in 37 (59.7%). Median interval from MRI to surgery was 7.9 weeks (interquartile range, 7.0-9.0). MRI tumor depth was <1 mm in 10 (16.9%), 1 to 5 mm in 30 (50.8%), and >5 mm in 21 (33.9%). Lymph node status was positive in 40 (61.5%), and vascular invasion was present in 16 (25.8%). Tumor response was associated with MRI tumor depth (p = 0.001), MRI lymph node status (p < 0.001) and vascular invasion (p = 0.009). Multivariate regression indicated >5 mm MRI tumor depth (OR = 0.08; 95% CI = 0.01-0.93; p = 0.04) and MRI lymph node positivity (OR = 0.12; 95% CI = 0.03-0.53; p = 0.005) were less likely to achieve a good response to neoadjuvant chemoradiotherapy.

LIMITATIONS: Generalizability is uncertain in centers with limited experience with MRI staging for rectal cancer.

CONCLUSION: MRI assessment of tumor depth and lymph node status in rectal cancer is associated to tumor response to neoadjuvant chemoradiotherapy. These factors should therefore be considered for stratification of patients for novel treatment strategies reliant on pathologic response to treatment or for the selection of poor-risk patients for intensified treatment regimens.

PMID: 22426259 [PubMed - in process]

FDG-PET assessment of rectal cancer response to neoadjuvant chemoradiotherapy is not associated with long-term prognosis: a prospective evaluation.

Dis Colon Rectum. 2012 Apr;55(4):378-86

Authors: Ruby JA, Leibold T, Akhurst TJ, Shia J, Saltz LB, Mazumdar M, Riedel ER, Larson SM, Guillem JG

Abstract

BACKGROUND: At present there is no defined role for routine FDG-PET in the preoperative evaluation of nonmetastatic rectal cancer.

OBJECTIVE: The primary objective of this study was to evaluate the ability of FDG-PET to predict long-term prognosis based on the response to neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer.

DESIGN: This was a prospective study.

SETTINGS: This study was performed at an academic, tertiary care, comprehensive cancer center.

PATIENTS: One hundred twenty-seven patients with locally advanced rectal cancer were enrolled between September 1999 and December 2005.

INTERVENTIONS: All patients underwent FDG-PET scans before and after neoadjuvant chemoradiotherapy.

MAIN OUTCOME MEASURES: FDG-PET parameters were evaluated by at least 2 study board-certified nuclear medicine physicians, and included mean standard uptake value, maximum standard uptake value, total lesion glycolysis, and visual response score. The main outcome measures were time to recurrence and disease-specific survival.

RESULTS: Of 127 patients, 82 (65%) were men, the median age was 60 years (range, 27-82), 110 patients had stage II/III disease, and 17 patients had stage IV disease. Median follow-up among survivors was 77 months (range, 1-115 months). Nine patients had unresectable metastatic disease and were excluded from the time-to-recurrence analysis. At 5 years, 74% (95% CI = 66%-81%) of patients had not had recurrences (locally and/or distantly). The 5-year disease-specific survival was 89% (95% CI = 81%-93%). On univariate analysis, visual response score and time to recurrence came closest to having an association (HR = 0.83, 95% CI = 0.68-1.01, p = 0.06). On multivariate analysis, the visual response score was not significant (p = 0.85). No FDG-PET parameter was associated with disease-specific survival.

CONCLUSIONS: Assessment of rectal cancer response to neoadjuvant chemoradiotherapy by FDG-PET provides no prognostic information. Therefore, serial FDG-PET before and after neoadjuvant chemoradiotherapy should not be performed for this purpose.

PMID: 22426260 [PubMed - in process]

Pelvic sepsis after IPAA adversely affects function of the pouch and quality of life.

Dis Colon Rectum. 2012 Apr;55(4):387-92

Authors: Kiely JM, Fazio VW, Remzi FH, Shen B, Kiran RP

Abstract

BACKGROUND: Pelvic sepsis after IPAA predisposes to pouch failure. There are limited data on long-term pouch function for patients with pelvic sepsis.

OBJECTIVE: The aim of this study was to investigate functional outcomes and quality of life for patients undergoing IPAA who develop pelvic sepsis and preserve their pouch long-term.

DESIGN: This study is based on retrospective analysis of prospectively accrued data.

SETTINGS: This study was conducted at a single-center institution.

PATIENTS: All patients undergoing IPAA from 1983 to 2007 were included.

MAIN OUTCOME MEASURES: The primary outcomes measured were functional outcomes (urgency, incontinence, bowel movements) and quality-of-life (restrictions, energy, happiness) parameters.

RESULTS: Two hundred (6.2%) of 3234 patients developed pelvic septic complications within 3 months of IPAA. In the comparison of complications at the time of IPAA for the 2 groups, patients with pelvic sepsis had higher rates of postoperative hemorrhage (13.5% vs 3.7%, p < 0.001), anastomotic leak (35% vs 3.7%, p < 0.001), wound infection (14% vs 7.4%, p < 0.001), and fistula formation (37% vs 7.1%, p < 0.001). The overall median follow-up was 7 years. Pelvic sepsis was associated with greater pouch failure (19.5% vs 4%, p < 0.001). For patients with follow-up (pelvic sepsis = 144, nonpelvic sepsis = 2677) with a retained pouch, for whom we compared functional outcomes and quality of life, incontinence was worse (never/rare: 69.5% vs 77.8%, p = 0.03). Urgency scores were lower in pelvic sepsis but not statistically significant. The overall Cleveland Global Quality of Life score (and components) in the sepsis group were significantly worse than in the nonsepsis group (0.74 vs 0.79, p < 0.001). Patients who developed sepsis were also less likely to recommend IPAA to others than patients who did not develop pelvic sepsis.

LIMITATIONS: This study was limited by the retrospective analysis and the use of questionnaires.

CONCLUSIONS: Pelvic sepsis after IPAA leads to worse functional outcomes and quality of life even when it does not lead to pouch failure. This finding argues for careful attention to preoperative and intraoperative planning and strategies aimed at reducing this complication after IPAA.

PMID: 22426261 [PubMed - in process]

Prognostic modeling of preoperative risk factors of pouch failure.

Dis Colon Rectum. 2012 Apr;55(4):393-9

Authors: Manilich E, Remzi FH, Fazio VW, Church JM, Kiran RP

Abstract

BACKGROUND: The prospect of pouch failure needs to be considered when evaluating the management strategy for patients who may be candidates for an ileo anal pouch. An ability to predict the likelihood and timing of failure preoperatively may influence surgical decision making.

OBJECTIVE: The aim of this study was to define a preoperative prognostic model for ileoanal pouch failure.

DESIGN: A novel random forest methodology was used to evaluate the prognostic significance of 21 preoperative potential risk factors for pouch failure. A forest of 3000 random survival trees was grown to estimate pouch failure for each patient and to identify important risk factors that maximize survival prediction.

SETTINGS: This study took place at a tertiary referral department at a major academic medical center.

PATIENTS: Patients undergoing an ileoanal pouch at this institution between 1983 and 2008 were included.

MAIN OUTCOME MEASURES: The primary outcome measured was pouch survival.

RESULTS: Between 1983 and 2008, 3754 patients underwent ileoanal pouch. Type of resection (total proctocolectomy vs completion proctectomy), type of anastomosis (stapled vs mucosectomy), patient diagnosis (mucosal ulcerative colitis and others vs Crohn’s disease) and diagnosis of diabetes had the strongest effect on pouch survival. Predicted survival was worse for completion proctectomy (HR, 1.44; 95% CI, 1.08-1.93), Crohn’s disease (HR, 2.37; 95% CI, 1.48-3.79), handsewn anastomosis (HR, 1.72; 95% CI, 1.23-2.42), and diabetes (HR, 2.31; 95% CI, 1.25-4.24). Pouch survival was worse for the oldest group of patients.

LIMITATIONS: This study was limited by its retrospective nature.

CONCLUSION: Random forest techniques applied to a large number of patients undergoing the ileoanal pouch identify factors associated with pouch failure. Attention directed at these factors may improve outcomes for these patients.

PMID: 22426262 [PubMed - in process]

Comparative quality of life in patients following abdominoperineal excision and low anterior resection for low rectal cancer.

Dis Colon Rectum. 2012 Apr;55(4):400-6

Authors: How P, Stelzner S, Branagan G, Bundy K, Chandrakumaran K, Heald RJ, Moran B

Abstract

BACKGROUND: It is widely believed that quality of life is worse after abdominoperineal excision then after low anterior resection. However, this view is not supported unequivocally.

OBJECTIVE: The aim of this study was to compare quality of life in patients 1 year following low anterior resection and abdominoperineal excision for low rectal cancer.

DESIGN: Data were collected prospectively on 62 patients undergoing low anterior resection (32) and abdominoperineal excision (30) for low rectal adenocarcinoma within 6 cm of the anal verge. Patients with metastatic disease were excluded. Quality of life was assessed by the use of the European Organization for Research and Treatment of Cancer’s QLQ-C30 and QLQ-CR38 modules and Coloplast stoma quality-of-life questionnaire. Bowel function was assessed by using the St Mark’s bowel function questionnaire. Quality of life in patients who had low anterior resection was compared with those who had abdominoperineal excision both preoperatively and 1 year after surgery.

SETTINGS: This study was conducted at 3 centers in the United Kingdom and 1 center in Europe.

PATIENTS: Included were consecutive patients with rectal cancer within 6 cm of the anal verge, all of whom provided written consent for participation.

MAIN OUTCOME MEASURES: Mann-Whitney U test comparisons of QLQ-C30 and QLQ-CR38 module scores for patients undergoing low anterior resection and abdominoperineal excision were the main outcomes measured.

RESULTS: Patients undergoing low anterior resection were younger (median age, 59.5 vs 67, p = 0.03) with higher tumors (4 vs 3, p < 0.001) and less likely to receive neoadjuvant therapy (p = 0.02). At 1 year postoperatively, global quality-of-life ratings were comparable, but patients undergoing abdominoperineal excision reported better cognitive (100 vs 83, p = 0.018) and social (100 vs 67, p = 0.012) function, and less symptomatology with respect to pain (0 vs 17, p = 0.027), sleep disturbance (0 vs 33, p = 0.013), diarrhea (0 vs 33, p = 0.017), and constipation (p = 0.021). Patients undergoing low anterior resection reported better sexual function (33 vs 0, p = 0.006), but 72% experienced a degree of fecal incontinence.

LIMITATIONS: This study was limited by its relatively small sample size.

CONCLUSION: Abdominoperineal excision should not be regarded as an operation that is inferior to low anterior resection in the management of low rectal cancer on the basis of quality of life alone.

PMID: 22426263 [PubMed - in process]

Early postoperative intraperitoneal chemotherapy following cytoreductive surgery for appendiceal mucinous neoplasms with isolated peritoneal metastasis.

Dis Colon Rectum. 2012 Apr;55(4):407-15

Authors: Wagner PL, Jones D, Aronova A, Shia J, Weiser MR, Temple LK, Chung KY, O’Reilly EM, Kelsen D, Paty PB, Nash GM

Abstract

BACKGROUND: Although cytoreductive surgery and intraperitoneal chemotherapy have been advocated as standard treatment for appendiceal neoplasms with isolated peritoneal metastasis, the optimal method of chemotherapy administration has not been established. At our institution, patients undergoing complete cytoreduction in this setting typically receive multiple cycles of early postoperative intraperitoneal chemotherapy.

OBJECTIVES: The aim of this study was to describe patients with appendiceal neoplasms and peritoneal dissemination treated with complete cytoreductive surgery and early postoperative intraperitoneal chemotherapy and to document associated time to progression and morbidity.

DESIGN: This is a retrospective study at a single specialty institution. Hospital and departmental databases were searched for patients presenting with primary appendiceal neoplasms undergoing cytoreductive surgery, placement of intraperitoneal port, and subsequent intraperitoneal chemotherapy from June 1995 to September 2009.

SETTINGS: This study was conducted at Memorial Sloan-Kettering Cancer Center.

PATIENTS: We identified 50 patients (30 female), median age 48 (range, 26-66) who met the criteria.

INTERVENTIONS: Cytoreductive surgery, placement intraperitoneal port, and intraperitoneal chemotherapy were performed.

RESULTS: All patients underwent intraperitoneal catheter placement after complete cytoreductive surgery, followed by a median of 4 cycles (range, 1-9) intraperitoneal 5-fluoro-2′-deoxyuridine (1000 mg/m daily for 3 days) plus leucovorin (240 mg/m). The median hospital length of stay was 9 days (maximum, 29). Thirty-four percent of the patients experienced complications; 12% experienced major complications (3 abdominal abscesses, 1 deep vein thrombosis, 1 abdominal hemorrhage, and 1 intraperitoneal port malfunction). There were no 30-day mortalities. Five-year recurrence-free interval was observed in 43%. Among 23 patients with recurrence, 18 had a recurrence only within the peritoneum. The median overall survival was 9.8 years.

LIMITATIONS: This is a retrospective study. Many patients had surgery first at other institutions; therefore, pathologic examination of resected material was not possible in every case. Other factors possibly impacting time to recurrence (ie, preoperative chemotherapy, duration between onset of disease and presentation to our institution) varied among patients and were not controlled for. In the absence of a control arm undergoing complete cytoreduction without early postoperative intraperitoneal chemotherapy, we did not ascertain whether intraperitoneal chemotherapy confers additional benefit.

CONCLUSIONS: Cytoreductive surgery plus multiple cycles of early postoperative intraperitoneal chemotherapy is safe, achieving survival results similar to published outcomes of other protocols (including hyperthermic intraperitoneal chemotherapy). Prospective trials are warranted to compare various methods of intraperitoneal chemotherapy in this setting.

PMID: 22426264 [PubMed - in process]

Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique.

Dis Colon Rectum. 2012 Apr;55(4):416-23

Authors: Fiore JF, Bialocerkowski A, Browning L, Faragher IG, Denehy L

Abstract

BACKGROUND: Standardized discharge criteria are considered valuable to reduce the risk of premature discharge and avoid unnecessary hospital stays. The most appropriate criteria to indicate readiness for discharge after colorectal surgery are unknown.

OBJECTIVE: The aim of this study is to achieve an international consensus on hospital discharge criteria for patients undergoing colorectal surgery.

DESIGN: Fifteen experts from different countries participated in a 3-round Delphi process. In round 1, experts determined which criteria best indicate readiness for discharge and described specific end points for each criterion. In rounds 2 and 3, experts rated their agreement with the use of a 5-point Likert scale.

MAIN OUTCOME MEASURES: Consensus was defined when criteria and end points were rated as agree or strongly agree by at least 75% of the experts in round 3.

RESULTS: Experts reached consensus that patients should be considered ready for hospital discharge when there is tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control with oral analgesia, ability to mobilize and self-care, and no evidence of complications or untreated medical problems. Specific end points were defined for each of the criteria. Experts also agreed that after these criteria are achieved, discharge may take place as soon as the patient has adequate postdischarge support and is willing to leave the hospital. If a stoma was constructed, the patient or the patient’s family should have received training on stoma care or had outpatient training arranged.

LIMITATIONS: The panel comprised mostly experts from developed countries. This may restrict the applicability of these discharge criteria in countries where there are dissimilar health care resources.

CONCLUSION: This Delphi study has provided substantial consensus on discharge criteria for patients undergoing colorectal surgery. We recommend that these criteria be used in clinical practice to guide decisions regarding patient discharge and applied in future research to increase the comparability of study results.

PMID: 22426265 [PubMed - in process]

Clostridium difficile of the ileum following total abdominal colectomy, with or without proctectomy: who is at risk?

Dis Colon Rectum. 2012 Apr;55(4):424-8

Authors: Tsiouris A, Neale JA, Reickert CA, Times M

Abstract

BACKGROUND: Clostridium difficile enteritis is considered a rare entity, although recent data suggest a significant increase in prevalence and incidence. There is paucity of data evaluating risk factors of C difficile enteritis following total colectomy.

OBJECTIVE: The aim of this study was to determine the incidence and risk factors of C difficile enteritis for patients who had undergone total abdominal colectomy with or without proctectomy.

DESIGN: This study involves a retrospective chart review of 310 patients. Univariate analysis was performed on potential risk factors (p ≤ 0.05) with the use of a logistic regression model, and a Fisher exact test was used for variables that had no occurrences of C difficile. These groups of variables were then examined in a multiple variate setting with stepwise logistic regression analysis.

SETTINGS: This study was conducted at a tertiary referral center.

PATIENTS: A data analysis was performed on patients who had undergone total abdominal colectomy with or without proctectomy who were tested for C difficile of the ileum.

RESULTS: Twenty-two of 137 patients that were tested (16%) were positive for C difficile of the ileum. Univariate analysis of known risk factors for C difficile demonstrated that black race was a protective factor against C difficile (p = 0.016). The multivariate analysis demonstrated that emergency surgery (p = 0.035), race (p = 0.003), and increasing age by decade (p = 0.033) were risk factors for C difficile.

LIMITATIONS: This study was limited by the small patient sample, and it was not a randomized trial.

CONCLUSIONS: Black race is protective, and whites are 4 times more likely to acquire C difficile of the ileum after undergoing a total abdominal colectomy with or without proctectomy. The data also demonstrated that an increased age by a decade and emergency surgery are risk factors for C difficile enteritis, whereas the described risk factors of C difficile of the colon and type of colon surgery do not appear to influence the risk of C difficile of the ileum.

PMID: 22426266 [PubMed - in process]

Obesity and laparoscopic colectomy: outcomes from the ACS-NSQIP database.

Dis Colon Rectum. 2012 Apr;55(4):429-35

Authors: Mustain WC, Davenport DL, Hourigan JS, Vargas HD

Abstract

BACKGROUND: Previous reports comparing outcomes of laparoscopic colectomy in obese vs nonobese patients from small, single-institution series have included few obese patients and have shown variable results, some suggesting that obesity has no impact on outcomes.

OBJECTIVE: We aimed to determine whether any intraoperative or short-term postoperative outcome of laparoscopic colectomy is affected by obesity, independent of other variables.

DESIGN: We performed a retrospective study comparing outcomes of patients undergoing laparoscopic colectomy grouped by BMI.

PATIENTS: We queried American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files for patients undergoing nonemergent, laparoscopic colectomy from 2005 through 2008. Cases with a secondary procedure (with the exception of laparoscopic lysis of adhesions, rigid proctosigmoidoscopy, or laparoscopic splenic flexure takedown) were excluded.

MAIN OUTCOME MEASURES: We analyzed operative time, length of stay, transfusion requirement, reoperation within 30 days, wound complications, pulmonary complications, sepsis/septic shock, deep venous thrombosis, renal failure/insufficiency, and death. We tested for differences in outcomes using χ tests or analyses of variance, and when differences between BMI classes were found, we performed multivariable regression to adjust for preoperative and intraoperative variables.

RESULTS: In an analysis of 9693 patients (30% with BMI ≥30), significant differences were found among BMI classes for length of stay, operative time, and wound complication. Operative time correlated with BMI class independent of other variables; length of stay did not. After adjustment of all available variables, obesity remained an independent risk factor for wound complication, and the odds ratios increased with increasing obesity class.

LIMITATIONS: Retrospective design and standardized outcome measures prevent examination of procedure-specific outcomes; therefore, this is not an intention-to-treat analysis.

CONCLUSIONS: These data confirm that, in patients undergoing laparoscopic colectomy, obesity is an independent risk factor for wound complications. Although obesity also increases operative time, the effect of obesity on wound complications remains after adjustment for this and other risk factors.

PMID: 22426267 [PubMed - in process]

Quality of life and functional outcome for individuals who underwent very early colectomy for familial adenomatous polyposis.

Dis Colon Rectum. 2012 Apr;55(4):436-43

Authors: Durno CA, Wong J, Berk T, Alingary N, Cohen Z, Esplen MJ

Abstract

BACKGROUND: The major manifestation of familial adenomatous polyposis is colorectal adenomas, which, if untreated, lead to colorectal cancer. The impact of IPAA on quality of life in adolescents with familial adenomatous polyposis is favorable. There is a group of children who develop polyps at a younger age requiring earlier colectomy. Little is known about this very young subgroup in relation to bowel function or quality of life.

OBJECTIVE: The aim of this study was to investigate the outcome in patients with familial adenomatous polyposis who had colectomy at ≤14 years.

DESIGN: A cross-sectional quantitative survey was designed to assess outcome. Standardized validated instruments included bowel/psychosocial functioning and quality of life.

RESULTS: Among 1337 patients with familial adenomatous polyposis from 409 kindreds, 4% (n = 59) of patients underwent colectomy at ≤14 years of age. Response rate was 84% (n = 32). The mean age at colectomy was 12 years (SD 2), with a current mean age of 24 years (SD 8.5). Fifty-seven percent of patients reported continence. Of the 43% reporting daytime or nighttime incontinence, the majority are <18 years (86%). Younger participants (currently less than 18 years of age) report more restrictions. Mental health is significantly lower among participants with incontinence. They report higher depression and anxiety symptoms, higher levels of intrusion and avoidance, and inferior mental health. The percentage of those worrying about risk of cancer is significantly higher in the younger group (71% vs 24%). Most patients (n = 24, 75%) have had surveillance endoscopy within the past 2 years.

LIMITATIONS: This study is limited by study generalizability, selection bias, and small sample size.

CONCLUSIONS: Twelve years after colectomy more than half of the patients have favorable bowel function. The rate of incontinence is high, especially among younger patients who have had a shorter time since surgery. Patients with incontinence reported lower psychosocial functioning, are very concerned about their cancer risk, and experience greater distress. This subgroup would benefit from added psychological interventions to enhance coping with familial adenomatous polyposis and surgery.

PMID: 22426268 [PubMed - in process]

Colonic volvulus: presentation and management in metropolitan Minnesota, United States.

Dis Colon Rectum. 2012 Apr;55(4):444-9

Authors: Swenson BR, Kwaan MR, Burkart NE, Wang Y, Madoff RD, Rothenberger DA, Melton GB

Abstract

BACKGROUND: Management approaches for colonic volvulus are infrequently described in the literature in the United States, and many studies only report operative cases.

OBJECTIVE: The aim of this study was to define the demographics, diagnostic and treatment approaches, and outcomes for patients with this disorder in the United States.

DESIGN: This study is a retrospective review.

SETTINGS: The study was conducted at a 7-hospital health system.

PATIENTS: All patients diagnosed with colonic volvulus by International Classification of Diseases, Ninth Revision code were included.

MAIN OUTCOME MEASURES: The primary outcomes measured were recurrence, complications, and mortality.

RESULTS: One hundred three cases of volvulus (50 sigmoid, 53 cecal) were identified in 92 patients. Compared with cecal volvulus, sigmoid volvulus was more common in men, patients with neurologic diagnoses, and residents of skilled nursing home. Eighty-five percent of the cases presented were acutely obstructed. The diagnosis was established by abdominal x-ray (17%), contrast enema study (27%), CT scan (35%), or laparotomy (17%). Abdominal x-rays were insufficient for definitive diagnosis in 85% of cecal and 49% of sigmoid cases (p = 0.002). All patients with cecal volvulus were treated surgically. Seventy-nine percent of patients with sigmoid volvulus underwent successful nonoperative reduction, of whom 38% had subsequent surgery. Fifty-eight percent of patients with sigmoid volvulus were treated operatively. Resection with primary anastomosis was chosen in most cases (78%). Resection with end ostomy (10%), reduction and pexy (7%), and reduction alone (4%) were other approaches. The mortality rate was 5% (cecal 0%, sigmoid 10%; p = 0.012). There were no readmissions for recurrent cecal volvulus. Nonoperative treatment for sigmoid volvulus often failed (48%). Complication rates were higher in sigmoid volvulus cases (cecal 17%, sigmoid 34%; p = 0.047).

LIMITATIONS: This study was limited by its retrospective, nonexperimental design.

CONCLUSIONS: Although incidences of cecal and sigmoid volvulus are similar in the present series, sigmoid volvuli are more common in men, individuals with neurologic disease, and residents of nursing homes. Plain radiograph is insufficient to confirm cecal volvulus. The diagnosis is most often made with CT scans. The nonoperative management of sigmoid volvulus is associated with a high recurrence rate.

PMID: 22426269 [PubMed - in process]

Complications after rectal prolapse surgery: does approach matter?

Dis Colon Rectum. 2012 Apr;55(4):450-8

Authors: Russell MM, Read TE, Roberts PL, Hall JF, Marcello PW, Schoetz DJ, Ricciardi R

Abstract

BACKGROUND: Data comparing surgical outcomes following abdominal and transperineal approaches for rectal prolapse are limited.

OBJECTIVE: We sought to identify differences in postoperative complications following abdominal vs transperineal approaches to rectal prolapse.

DESIGN: We studied a retrospective cohort in the American College of Surgeon’s National Surgical Quality Improvement Program from January 2005 through December 2008.

PATIENTS: We identified all patients who underwent surgical treatment for rectal prolapse.

INTERVENTION: We compared surgical outcomes of standard abdominal approaches compared with standard transperineal approaches to rectal prolapse.

MAIN OUTCOME MEASURES: The primary outcomes measured were the validated morbidity outcomes and 30-day mortality.

RESULTS: During the study period, 1485 patients underwent rectal prolapse surgery (706 abdominal and 779 transperineal). Patients treated with abdominal approaches had significantly higher rates of infectious (9.8% vs 3.7%) and overall (12.9% vs 7.6%) complications in comparison with those treated with transperineal approaches. On multivariate analysis, risk factors for overall complications were ASA class 4 (OR 6.4) and abdominal surgery (OR 2.3), whereas an albumin level of ≥ 2.5 was protective (OR 0.05). Significant predictors of infectious complications were ASA class 4 (OR 7.5), BMI >25 (OR 1.8), and rectal prolapse surgery performed with an abdominal approach (OR 2.8).

LIMITATIONS: The retrospective design introduces potential selection bias.

CONCLUSIONS: Abdominal surgery for rectal prolapse is a predictor of both infectious and overall complications. Patients with significant comorbidities or a high BMI are at particularly high risk for complications and may be better suited for a transperineal rather than abdominal approach for the treatment of rectal prolapse.

PMID: 22426270 [PubMed - in process]

Factors influencing oncological outcomes in patients who develop pulmonary metastases after curative resection of colorectal cancer.

Dis Colon Rectum. 2012 Apr;55(4):459-64

Authors: Kim CH, Huh JW, Kim HJ, Lim SW, Song SY, Kim HR, Na KJ, Kim YJ

Abstract

BACKGROUND: The prognostic factors after pulmonary resection in patients with colorectal pulmonary metastases remain controversial.

OBJECTIVE: The study aimed to identify the predicting factors for oncological outcomes after curative resection in patients with colorectal cancer and pulmonary metastases.

DESIGN: This study is a retrospective review of prospectively collected data.

SETTING: This study was conducted at a tertiary care hospital/referral center in South Korea.

PATIENTS: Between January 2000 and June 2010, 105 patients who developed pulmonary metastases after curative resection for colorectal cancer were enrolled. Forty-eight patients underwent pulmonary resection, and the remaining 58 were given chemotherapy and/or best supportive care.

MAIN OUTCOME MEASURES: The primary outcomes measured were the predictive factors of survival and recurrence.

RESULTS: During the 35.9-month median follow-up period, 3- and 5-year overall survival rates were 54.6% and 30.4%. On multivariate analysis, absence of adjuvant chemotherapy after pulmonary metastases (p = 0.003), presence of extrapulmonary metastases (p = 0.001), elevated prelaparotomy serum CEA level (p = 0.015), and absence of pulmonary resection (p = 0.048) were independent prognostic factors for poor overall survival. In patients who underwent pulmonary resection, the 3-year pulmonary recurrence-free survival rate was 78.3%. On multivariate analysis, elevated prelaparotomy serum CEA level (p = 0.018) and disease-free interval ≤ 12 months (p = 0.008) were independent risk factors associated with pulmonary re-recurrence after pulmonary resection.

LIMITATIONS: This study took place at a single institution and had a small sample size.

CONCLUSION: Although we admit, to some degree, the benefits of the selection mechanism, pulmonary metastasectomy from colorectal cancer may improve survival after curative resection of colorectal cancer. Adjuvant chemotherapy, extrapulmonary metastases, and prelaparotomy CEA value are independent prognostic factors for overall survival. Prelaparotomy serum CEA level may be an especially reliable predictor of both overall survival and recurrence-free survival after pulmonary metastasectomy in patients who undergo curative resection for colorectal cancer.

PMID: 22426271 [PubMed - in process]

Short-term effects of neoadjuvant chemoradiotherapy on internal anal sphincter function: a human in vitro study.

Dis Colon Rectum. 2012 Apr;55(4):465-72

Authors: Lorenzi B, Brading AF, Martellucci J, Cetta F, Mortensen NJ

Abstract

BACKGROUND: Neoadjuvant chemoradiotherapy is recommended in the treatment of locally advanced rectal cancer. Studies have suggested that chemoradiotherapy adversely affects anorectal function. However, the functional implication and the underlying neuromyogenic changes involved in radiation-induced damage are poorly understood.

OBJECTIVE: This study evaluated the functional changes following chemoradiotherapy on the internal anal sphincter.

DESIGN AND PATIENTS: This article describes an in vitro study on the internal anal sphincter collected from patients undergoing abdominoperineal resection or proctectomy. Five patients were treated by surgery alone (control group), and 6 received preoperative chemoradiotherapy (treatment group). Sphincter strips were mounted in organ bath, and the responses to electrical field stimulation and drugs were monitored.

SETTINGS: The study was performed at the University of Oxford.

MAIN OUTCOME MEASURES: The end points of this study were to investigate whether chemoradiotherapy has any significant effects on internal anal sphincter function and, subsequently, to establish the type of injury induced.

RESULTS: Chemoradiotherapy strips developed similar tone, but significantly lower spontaneous activity (p = 0.001) than controls. Electrical field stimulation induced relaxation, followed by contraction. At 50 Hz, electrical field stimulation produced 25.6 ± 4.9% (mean ± SE) of maximum relaxation followed by a contraction of 5.5 ± 0.9% of basal tone in chemoradiotherapy strips i9n comparison with 47.0 ± 6.2% (p = 0.009) and 17.7 ± 4.0% (p = 0.007) in controls. Relaxation was significantly attenuated by N-nitro-L-arginine. Significant differences were found in responses to carbachol (p = 0.018) and phenylephrine (p = 0.022), but not to sodium nitroprusside.

LIMITATIONS: This work was limited by the relatively small number of patients enrolled, because of the difficulty of finding human tissue for laboratory studies, and the lack of long-term results.

CONCLUSIONS: Chemoradiotherapy significantly impairs internal anal sphincter function and intrinsic nerves seem more susceptible than smooth muscle. The exclusion of anal canal from the radiation field is recommended, when oncologically safe.

PMID: 22426272 [PubMed - in process]

Internal anal sphincter parasympathetic-nitrergic and sympathetic-adrenergic innervation: a 3-dimensional morphological and functional analysis.

Dis Colon Rectum. 2012 Apr;55(4):473-81

Authors: Moszkowicz D, Peschaud F, Bessede T, Benoit G, Alsaid B

Abstract

BACKGROUND: Little detailed information is available concerning morphological and functional autonomic nerve supply to the internal anal sphincter. However, denervation of the sphincter potentially affects anal function after rectal surgery for cancer.

OBJECTIVE: The aim of this study was to identify the location and type (nitrergic, adrenergic, and cholinergic) of nerve fibers in the internal anal sphincter and to provide a 3-dimensional representation of their structural relationship in the human fetus.

MATERIALS AND METHODS: serial transverse sections were obtained from 14 human fetuses (7 male, 7 female, 15-31 weeks of gestation) and were studied histologically and immunohistochemically; digitized serial sections were used to construct a 3-dimensional representation of the pelvis.

MAIN OUTCOMES MEASURES: The location and type of internal anal sphincter nerves were assessed qualitatively.

RESULTS: Posteroinferior fibers originating from the inferior hypogastric plexus posteroinferior angle projected to the posterolateral and posterior rectal wall and internal anal sphincter, forming the inferior rectal plexus. The inferior rectal plexus contained vesicular acetylcholine transporter-positive (cholinergic), tyrosine hydroxylase-positive (adrenergic/sympathetic), and neural nitric oxide synthase-positive (nitrergic) fibers. The intrasphincteric vesicular acetylcholine transporter-positive fibers included both neural nitric oxide synthase-negative fibers and neural nitric oxide synthase-positive fibers (nitrergic-parasympathetic).

LIMITATIONS: The study focused on topographic and functional anatomy, so that quantitative data were not obtained. A small number of fetal specimens were available.

CONCLUSIONS: We report the precise location and distribution of the autonomic neural supply to the internal anal sphincter. This description contributes to the understanding of neurogenic postoperative sphincteric dysfunction. Three-dimensional cartography of pelvic-perineal neurotransmitters provides an anatomical and physiological basis for the selection and development of pharmacological agents to be used in the treatment of primary or postoperative continence and evacuation disorders.

PMID: 22426273 [PubMed - in process]

Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review.

Dis Colon Rectum. 2012 Apr;55(4):482-90

Authors: Glasgow SC, Lowry AC

Abstract

BACKGROUND: Thorough and objective analysis of long-term results following anal sphincter repair for fecal incontinence will permit the correct application of this operation in the context of newer treatment methods.

OBJECTIVE: This investigation aimed to comprehensively review outcomes beyond 5 years in patients undergoing anal sphincter repair for fecal incontinence.

DATA SOURCES: A systematic review of Embase and MEDLINE articles published between January 1991 and December 2010 was conducted; additional studies were identified by hand-searching bibliographies.

STUDY SELECTION: A 2-step process was used for screening articles examining sphincter repair or sphincteroplasty in adults with fecal incontinence, with a minimum follow-up of 60 months.

MAIN OUTCOME MEASURES: Subjective or objective assessment of fecal incontinence in the postoperative period was completed.

RESULTS: Data from 16 studies were examined, comprising nearly 900 repairs. There was significant heterogeneity in outcome measures, although most articles utilized at least one established incontinence instrument. In general, most series reported an initial subjectively “good” outcome in the majority of patients, with declines in this proportion over longer follow-up. There was poor correlation between quality of life and the severity of fecal incontinence, with all articles reporting high overall patient satisfaction even if continence declined with time or adaptive measures were needed. No consistent predictive factors for failure were identified.

LIMITATIONS: This study was limited by the paucity of level I data with an adequate length of follow-up.

CONCLUSION: Despite worsening results over time, most patients remain satisfied with their surgical outcome postsphincteroplasty. Efforts should be directed at identifying patients who may do poorly following sphincter repair, as well as establishing standardized long-term outcome benchmarks for comparing novel techniques for treating fecal incontinence.

PMID: 22426274 [PubMed - in process]

Pilonidal disease: time to reevaluate a common pain in the rear!

Dis Colon Rectum. 2012 Apr;55(4):491-3

Authors: Loganathan A, Arsalani Zadeh R, Hartley J

PMID: 22426275 [PubMed - in process]

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons, and the American Society of Colon and Rectal Surgeons: evidence based reviews in surgery – colorectal surgery.

Dis Colon Rectum. 2012 Apr;55(4):494-6

Authors: Temple LK, Forbes SS, Roberts PL,

PMID: 22426276 [PubMed - in process]

Randomized trial of the hemorrhoid laser procedure vs rubber band ligation: 6-month follow-up.

Dis Colon Rectum. 2012 Apr;55(4):e45; author reply e45

Authors: Jongen J, Kahlke V

PMID: 22426277 [PubMed - in process]

Laparoscopy…For all?

Dis Colon Rectum. 2012 May;55(5):499-500

Authors: Etzioni DA

PMID: 22513426 [PubMed - in process]

Laparoscopic colectomy for the treatment of cancer has been widely adopted in the United States.

Dis Colon Rectum. 2012 May;55(5):501-8

Authors: Fox J, Gross CP, Longo W, Reddy V

Abstract

BACKGROUND: : Fewer than 10% of patients with colon cancer in the United States are reportedly treated with a laparoscopic colectomy despite the benefits it has over the open approach. This estimate, however, may be artificially low because of inaccurate case identification.

OBJECTIVE: : The aim of this study was to estimate the proportion of colon resections performed laparoscopically for the treatment of colon cancer and to identify factors associated with its use.

DESIGN: : This study is a retrospective review of the 2008 to 2009 Nationwide Inpatient Sample. SETTINGS, PATIENTS, INTERVENTIONS:: Adult patients with a diagnosis of colon cancer who underwent an elective colectomy were included.

MAIN OUTCOME MEASURES: : The overall proportion of colon resections performed laparoscopically was calculated. Multivariable regression modeling was used to identify patient and hospital characteristics associated with undergoing a laparoscopic procedure.

RESULTS: : During the study period, 9075 (weighted = 45,549) patients were identified with 50% treated via the laparoscopic approach. Patients were more likely to undergo a laparoscopic procedure if their median annual income was $63,000+ based on home zip code (adjusted relative risk = 1.08 (1.02-1.16)) and less likely if they were 70+ years of age (adjusted relative risk = 0.93 (0.87-1.00)), female (adjusted relative risk = 0.96 (0.92-0.99)), and had Medicaid (adjusted relative risk =0.84 (0.73-0.97)), or 3+ chronic conditions (adjusted relative risk = 0.84 (0.79-0.89)). Treatment at teaching hospitals (adjusted relative risk =1.10 (1.00-1.20)) and high-volume centers (adjusted relative risk =1.41 (1.22-1.63)) was associated with undergoing a laparoscopic colectomy, whereas treatment at rural hospitals was associated with less frequent use of laparoscopic colectomy (adjusted relative risk = 0.76 (0.64-0.90)).

LIMITATIONS: : This study is subject to the limitations of using administrative data.

CONCLUSIONS: : There has been widespread adoption of the laparoscopic approach to colon resection for cancer in the United States. Disparities in access remain, with application of this technique favoring patients with a higher socioeconomic status and those able to be treated at higher-volume, academic, and nonrural centers.

PMID: 22513427 [PubMed - in process]

Population-based evaluation of adenosquamous carcinoma of the colon and rectum.

Dis Colon Rectum. 2012 May;55(5):509-14

Authors: Masoomi H, Ziogas A, Lin BS, Barleben A, Mills S, Stamos MJ, Zell JA

Abstract

BACKGROUND: : Information about adenosquamous carcinoma of the colon and rectum is scarce because of its extremely low incidence.

OBJECTIVE: : The aim of this study was to examine the prognostic significance of a histological diagnosis of adenosquamous carcinoma in comparison with adenocarcinoma of the colon and rectum.

DESIGN: : This study was retrospective in design.

SETTING: : California Cancer Registry data from 1994 through 2004 with follow-up through 2008 were analyzed.

PATIENTS: : Patients were included whose cancer of the colon and rectum, excluding the anus with a tumor histology of adenocarcinoma and adenosquamous carcinoma, was surgically treated.

MAIN OUTCOME MEASURES: : The primary outcomes measured were histology-specific survival analyses (with the use of the Kaplan-Meier method), and overall and colorectal-specific mortality (with the use of multivariable Cox proportional hazards regression analyses).

RESULTS: : A total of 111,263 adenocarcinoma and adenosquamous carcinoma of colon and rectal cancer cases were identified (adenocarcinoma, 99.91%; adenosquamous carcinoma, 0.09%). There was no significant difference in sex, age, race, and socioeconomic status between the 2 groups. The most common location of adenocarcinoma and adenosquamous carcinoma was the right and transverse colon. The adenosquamous carcinoma group was significantly associated with a higher rate of metastasis at the time of operation (adenosquamous carcinoma, 36.56% vs adenocarcinoma, 13.92%) and with poorly differentiated tumor grade (adenosquamous carcinoma, 65.96% vs adenocarcinoma, 19.74%) in comparison with the adenocarcinoma group. The median overall survival time was significantly greater in the adenocarcinoma group (82.4 months) in comparison with the adenosquamous carcinoma group (35.3 months). With the use of multivariable hazard regression analyses, adenosquamous carcinoma histology was independently associated with increased overall mortality (hazard ratio, 1.67) and colorectal-specific mortality (hazard ratio, 1.69) in comparison with adenocarcinoma.

CONCLUSIONS: : This is one of the largest studies of adenosquamous carcinoma of the colon and rectum to date. This uncommon colorectal cancer subtype was associated with higher overall and colorectal-specific mortality in comparison with adenocarcinoma. Among colorectal cancer cases, adenosquamous carcinoma histology should be considered a poor prognostic feature.

PMID: 22513428 [PubMed - in process]

High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses.

Dis Colon Rectum. 2012 May;55(5):515-21

Authors: Bonnet S, Berger A, Hentati N, Abid B, Chevallier JM, Wind P, Delmas V, Douard R

Abstract

BACKGROUND: : There is no demonstrated benefit of high-tie versus low-tie vascular transections in colorectal cancer surgery.

OBJECTIVE: : The aim of this study was to compare the effects of high-tie and low-tie vascular transections on colonic length after oncological sigmoidectomy, the theoretical feasibility of colorectal anastomosis at the sacral promontory, and straight or J-pouch coloanal anastomosis after rectal cancer surgery with total mesorectal excision.

DESIGN: : This study is an anatomical study on surgical techniques.

SETTINGS: : This study was conducted in a surgical anatomy research unit.

PATIENTS: : Thirty fresh nonembalmed cadavers were randomly assigned to high-tie and low-tie groups (n = 15).

INTERVENTIONS: : Oncological sigmoidectomy followed by total mesorectal excision was performed.

MAIN OUTCOME MEASURES: : The distances from the proximal colon limb to the lower edge of the pubis symphysis were recorded after each step of vascular division.

RESULTS: : The successive mean gains in length in high-tie vs low-tie vascular transections were 2.9±1.2 cm vs 3.1 ± 1.8 cm (p = 0.83) after inferior mesenteric artery division, 8.1 ± 3.1 cm vs 2.5 ± 1.2 cm (p = 0.0016) after inferior mesenteric vein division at the lower part of the pancreas, 8.1 ± 3.8 cm vs 3.3 ± 1.7 cm (p = 0.0016) after sigmoidectomy. The mean cumulative gain in length was significantly higher in high-tie vs low-tie vascular transections (19.1 ± 3.8 vs 8.8 ± 2.9 cm, p = 0.00089). After secondary left colic artery division, the gain in length was similar to that of the high-tie group (17 ± 3.1 vs 19.1 ± 3.8 cm) (p = 0.089). Colorectal anastomosis at the promontory and straight and J-pouch coloanal anastomosis feasibility rates were 100% in the high-tie group, 87%, 53%, and 33% in the low-tie group, but 100%, 100%, and 87% after secondary left colic artery division.

LIMITATIONS: : This anatomical study, based on cadavers rather than live patients, does not evaluate colon limb vascularization.

CONCLUSIONS: : The gain in colonic length is 10 cm greater for high-tie vascular transections. With low-tie vascular transections, high inferior mesenteric vein division produced a small additional gain in length, and secondary left colic artery division produced the same length gain as high-tie vascular transections.

PMID: 22513429 [PubMed - in process]

The Incidence and Risk Factors of Metachronous Colorectal Cancer: An Indication for Follow-up.

Dis Colon Rectum. 2012 May;55(5):522-31

Authors: Mulder SA, Kranse R, Damhuis RA, Th Ouwendijk RJ, Kuipers EJ, van Leerdam ME

Abstract

BACKGROUND: : Patients with colorectal cancer are at risk for developing metachronous colorectal cancer. The purpose of posttreatment surveillance is to detect and remove premalignant lesions to prevent metachronous colorectal cancer.

OBJECTIVE: : The aim of this study was to investigate the incidence of and predictive factors for metachronous colorectal cancer in patients with newly diagnosed colorectal cancer.

DESIGN AND PATIENTS: : The data on all patients with newly diagnosed colorectal cancer between 1995 and 2006 were obtained from the Rotterdam Cancer Registry in The Netherlands and studied for metachronous colorectal cancer.

MAIN OUTCOME MEASURES: : The annual incidence rate and the standardized incidence ratios were calculated.

RESULTS: : In total, colorectal cancer was diagnosed in 10,283 patients; there were 39,974 person-years of follow-up. The mean annual incidence rate of metachronous colorectal cancer was 314/100,000 person-years at risk during 10 years of follow-up, corresponding with a mean annual incidence of 0.3% and a cumulative incidence of 1.1% at 3 years, 2.0% at 6 years, and 3.1% at 10 years. The incidence of metachronous colorectal cancer after resection of a first colorectal cancer is significantly higher than the incidence of colorectal cancer in an age- and sex-matched general population (standardized incidence ratio 1.3, 95% CI 1.1-1.5). This difference is especially seen during the first 3 years after first colorectal cancer diagnosis (standardized incidence ratio 1.4, 95% CI 1.1-1.8). The presence of synchronous colorectal cancer was the only significant risk factor for developing metachronous colorectal cancer (relative risk 13.9, 95% CI 4.7-41.0).

CONCLUSIONS: : Despite the availability of colonoscopy, metachronous colorectal cancer is still seen during follow-up in patients with colorectal cancer; the highest risk is during the first 3 years after initial diagnosis. For this reason, a follow-up colonoscopy is useful at a short-term interval after colorectal cancer diagnosis. The presence of synchronous colorectal cancer at the time of first colorectal cancer diagnosis is the only predictive risk factor for developing metachronous colorectal cancer. Tailored surveillance programs may be considered in patients with a diagnosis of synchronous tumors.

PMID: 22513430 [PubMed - in process]

Genetic Variation in the Transforming Growth Factor-β-Signaling Pathway, Lifestyle Factors, and Risk of Colon or Rectal Cancer.

Dis Colon Rectum. 2012 May;55(5):532-40

Authors: Slattery ML, Lundgreen A, Wolff RK, Herrick JS, Caan BJ

Abstract

BACKGROUND: : The transforming growth factor-β-signaling pathway has been identified as being involved in colorectal cancer.

OBJECTIVE: : The aim of this study was to determine how diet and lifestyle factors in combination with genetic variation in the transforming growth factor-β-signaling pathway alters colorectal cancer risk.

DESIGN: : We used data from 2 population-based case-control studies.

PATIENTS: : Participants included patients with colon cancer (n = 1574) and controls (n = 1970) and patients with rectal cancer ( n = 791) and controls (n = 999).

MAIN OUTCOME MEASURES: : The primary outcomes measured were newly diagnosed cases of colon or rectal cancer.

RESULTS: : Colon and rectal cancer risk increased with the number of at-risk genotypes within the transforming growth factor-β-signaling pathway (OR 3.68, 95% CI 2.74,4.94 for colon cancer; OR 3.89, 95% CI 2.66,5.69 for rectal cancer). A high at-risk lifestyle score also resulted in significant increased risk with number of at-risk lifestyle factors (OR 2.99, 95% CI 2.32,3.85 for colon cancer; OR 3.37, 95% CI 2.24,5.07 for rectal cancer). The combination of high-risk genotype and high-risk lifestyle results in the greatest increase in risk (OR 7.89, 95% CI 4.45,13.96 for colon cancer; OR 8.75, 95% CI 3.66,20.89 for rectal cancer).

LIMITATIONS: : The study results need validation in other large studies of colon and rectal cancer.

CONCLUSIONS: : In summary, our data suggest that there is increased colon and rectal cancer risk with increasing number of at-risk genotypes and at-risk lifestyle factors. Although the integrity of the pathway can be diminished by a number of high-risk genotypes, this risk can be offset, in part, by maintaining a healthy lifestyle.

PMID: 22513431 [PubMed - in process]

The Management of Anastomotic Pouch Sinus After IPAA.

Dis Colon Rectum. 2012 May;55(5):541-8

Authors: Ahmed Ali U, Shen B, Remzi FH, Kiran RP

Abstract

BACKGROUND: : Anastomotic sinus is a relatively uncommon complication after an IPAA. Disease course is poorly defined, and management can be challenging.

OBJECTIVE: : The purpose of this study was to evaluate the frequency, management, and outcome of anastomotic pouch sinus.

DESIGN: : This research is a retrospective cohort study from a prospectively collected database.

SETTING: : The investigation took place in a high-volume specialized colorectal surgery department.

PATIENTS: : Patients with an anastomotic sinus after pouch surgery from 1997 to 2009 were included.

MAIN OUTCOMES MEASURES: : The primary outcomes measured were sinus healing and pouch failure.

RESULTS: : Of 2286 patients who underwent an IPAA, 45 (2.0%) patients were identified with an anastomotic pouch sinus. There were 32 (71%) males, and the mean age was 40 (±13) years. The pouch sinus was initially managed by observation in 23 (51%) patients, drainage of the sinus in 9 (20%) patients, unroofing of the sinus tract in 8 (18%) patients, sinus closure in 3 (7%) patients, and a diverting ileostomy in 2 (4%) patients. In 28 patients (62%), subsequent treatment was necessary. Sinus healing was achieved in 27 (60%) patients, whereas 15 (33%) eventually developed pouch failure. Of the treatment modalities applied, a strategy with observation as initial treatment was the most successful with a healing rate of 65%. The healing rate was significantly lower in symptomatic patients in comparison with asymptomatic patients (30% vs 84%, p = 0.001). Pouch failure was also higher (45% vs 24%, p = 0.14). No other factors associated with healing rate or pouch failure were identified.

LIMITATIONS: : This study was limited by its nonrandomized retrospective design.

CONCLUSION: : Anastomotic pouch sinuses after pouch surgery are associated with a high rate of pouch failure. Symptomatic presentation is a significant predictor for low healing rates and is associated with a high risk of pouch failure. Observation and watchful monitoring is the initial treatment of choice when permitted by the patient’s condition.

PMID: 22513432 [PubMed - in process]

Increased crypt apoptosis is a feature of autoimmune-associated chronic antibiotic refractory pouchitis.

Dis Colon Rectum. 2012 May;55(5):549-57

Authors: Jiang W, Goldblum JR, Lopez R, Lian L, Shen B

Abstract

BACKGROUND: : Restorative proctocolectomy with IPAA is the surgical treatment of choice in patients with ulcerative colitis who require colectomy. Pouchitis is the most common long-term complication in patients with IPAA. While immune-mediated disorders frequently coexist with IBD, they appear to be associated with an increased risk for chronic antibiotic-refractory pouchitis.

OBJECTIVE: : This study aimed to evaluate histologic features of autoimmune-associated chronic antibiotic-refractory pouchitis in comparison with controls and to assess their possible diagnostic utility.

DESIGN: : Clinical definition for autoimmune-associated chronic pouchitis included 1) chronic antibiotic-refractory pouchitis with response only to corticosteroids, immunomodulators, or biologics; 2) positive serum autoantibodies, including antinuclear antibody, rheumatoid factor, and antimicrosomal antibody; and 3) concurrent immune-mediated disorders. Various histologic features of pouch biopsy specimens were evaluated.

SETTING: : The investigation was conducted at a tertiary referral center.

PATIENTS: : From our Pouchitis Registry, all eligible patients with autoimmune-associated pouchitis (n = 17) were included. The control groups included 16 patients with nonautoimmune-associated chronic antibiotic-refractory pouchitis, 39 with antibiotic-responsive pouchitis, and 19 patients with normal pouches. Various histologic features of pouch biopsy specimens were evaluated.

RESULTS: : In comparison with the control groups, the autoimmune-associated pouchitis group showed a significant increase in deep crypt apoptosis (p < 0.001). It also showed more pyloric gland metaplasia in comparison with antibiotic-responsive pouchitis and normal pouches. With the use of apoptosis score which we developed as a diagnostic marker for autoimmune-associated chronic antibiotic-refractory pouchitis, we constructed a receiver operating curve and obtained an area-under-curve value of 0.89 (95% CI: 0.79, 0.99).

CONCLUSION: : Increased deep crypt apoptosis is a distinctive histologic feature of autoimmune-associated chronic antibiotic-refractory pouchitis, and this feature may aid in the diagnosis and differential diagnosis in pouchitis.

PMID: 22513433 [PubMed - in process]

Influence of risk factors on the safety of ileocolic anastomosis in Crohn’s disease surgery.

Dis Colon Rectum. 2012 May;55(5):558-62

Authors: Tzivanakis A, Singh JC, Guy RJ, Travis SP, Mortensen NJ, George BD

Abstract

BACKGROUND: : Ileocecal resection is the most commonly performed operation in patients with Crohn’s disease. Anastomotic-associated complications, with their associated morbidity, are the most feared risks of surgery.

OBJECTIVE: : This study aimed to assess the influence of a variety of putative risk factors in a homogenous group of patients undergoing first or subsequent surgery for Crohn’s disease to quantify the cumulative risk for anastomotic-associated complications.

DESIGN AND PATIENTS: : All patients undergoing ileocecal or ileocolic resections for Crohn’s disease from 2000 to 2010 were studied with the use of a prospective database. Demographics, operative details, possible risk factors, and anastomotic-associated complications were recorded. Patients having strictureplasties, multiple resections, or subtotal colonic resections were excluded from analysis. Statistical analysis was by univariate analysis (Mann-Whitney U test) and binary logistic regression.

OUTCOMES: : An anastomotic-associated complication was defined as a proven anastomotic leak, postoperative fistulation, or intra-abdominal abscess formation.

RESULTS: : Two hundred seven patients (109 female) with a median age of 35 years (range, 13-75 years) were identified. One hundred seventy-three underwent primary anastomosis, 94 as an emergency procedure. Fifty-three had laparoscopic (5 converted) procedures. Nineteen of 173 anastomotic complication events (11%) were recorded. Steroid usage (OR 2.67, 95% CI 1.0-7.2) and the presence of preoperative abscess formation (OR 3.4, 95% CI 1.2-9.8) were identified as independent predictors of anastomotic-associated complications. In the absence of both steroids and intra-abdominal abscess, the risk of anastomotic complications was 6%, which increased to 14% if either risk factor was present. When both risk factors were present, complication rates reached 40%.

CONCLUSION: : Steroid usage and preoperative abscess were associated with higher rates of anastomotic complications following ileocolic resection for Cohn’s disease. When both risk factors are present, it is best to avoid primary anastomosis.

PMID: 22513434 [PubMed - in process]

Does preoperative immunosuppression influence unplanned hospital readmission after surgery in patients with Crohn’s disease?

Dis Colon Rectum. 2012 May;55(5):563-8

Authors: White EC, Melmed GY, Vasiliauskas E, Dubinsky M, Ippoliti A, McGovern D, Targan S, Fleshner P

Abstract

BACKGROUND: : Steroids, immunomodulators, and biologics, often in combination with one another, are frequently used in the treatment of Crohn’s disease. Retrospective studies have yielded conflicting results regarding the influence of preoperative immunosuppressive therapy on postoperative complications after surgery in Crohn’s disease. Unplanned hospital readmission is considered to be an index of quality surgical care.

OBJECTIVE: : The aim of this study was to examine the association, if any, between the number of preoperative immunosuppressive therapies and unplanned hospital readmission after surgery in patients with Crohn’s disease.

DESIGN: : Consecutive patients with Crohn’s disease requiring abdominal surgery were identified from a prospectively maintained database. Preoperative immunosuppressive therapy within 3 months before surgery was categorized into 3 classes: steroids, immunomodulators, and biologics.

MAIN OUTCOME MEASURES: : Unplanned readmission occurring within 30 days of hospital discharge was assessed. Trend analysis was performed with the use of the Cochrane-Armitage test.

RESULTS: : The study group included 338 patients. Preoperative medical therapy included steroids (n = 199; 59%), immunomodulators (n = 162; 48%), and biologics (n = 59; 18%). Sixty-three patients (19%) were not treated with any immunosuppressive medications preoperatively, whereas 148 patients (44%), 108 patients (32%), and 19 patients (6%) were treated with 1, 2, or 3 classes of immunosuppressive medications. Twenty-eight patients (8.3%) had an unplanned readmission. The incidence of unplanned readmission was similar among patients treated with steroids (11%), immunomodulators (9%), and biologics (12%). The incidence of unplanned readmission was 3%, 7%, 11%, and 16% in patients treated with 0, 1, 2, or 3 preoperative medication classes (trend analysis p = 0.02). No significant differences were observed between patient groups treated with 0, 1, 2, or 3 preoperative immunosuppressive therapies with respect to patient, disease, or surgical factors.

CONCLUSIONS: : Unplanned hospital readmission occurs frequently (8.3%) after surgery for Crohn’s disease. Combination immunosuppressive therapy before surgery in patients with Crohn’s disease appears to be associated with an increased incidence of postoperative unplanned hospital readmission.

PMID: 22513435 [PubMed - in process]

Risk factors for anastomotic leakage after colectomy.

Dis Colon Rectum. 2012 May;55(5):569-75

Authors: Leichtle SW, Mouawad NJ, Welch KB, Lampman RM, Cleary RK

Abstract

BACKGROUND: : Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication.

OBJECTIVE: : The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis.

DESIGN: : The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed.

SETTING: : This study was performed at academic and community medical centers in the state of Michigan.

PATIENTS: : Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010.

MAIN OUTCOME MEASURES: : Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage.

RESULTS: : Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003.

LIMITATIONS: : The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review.

CONCLUSION: : Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.

PMID: 22513436 [PubMed - in process]

A Diagnostic Accuracy Meta-analysis of Endoanal Ultrasound and MRI for Perianal Fistula Assessment.

Dis Colon Rectum. 2012 May;55(5):576-85

Authors: Siddiqui MR, Ashrafian H, Tozer P, Daulatzai N, Burling D, Hart A, Athanasiou T, Phillips RK

Abstract

BACKGROUND: : Imaging modalities such as endoanal ultrasound or MRI can be useful preoperative adjuncts before the appropriate surgical intervention for perianal fistulas.

OBJECTIVES: : We present a systematic review of published literature comparing endoanal ultrasound with MRI for the assessment of idiopathic and Crohn’s perianal fistulas.

DESIGN: : A meta-analysis was performed to obtain pooled values for specificity and sensitivity.

SETTINGS: : Electronic databases were searched from January 1970 to October 2010 for published studies.

PATIENTS AND INTERVENTIONS: : Four studies were used in our analysis. There were 241 fistulas in the ultrasound group and 240 in the magnetic resonance group.

RESULTS: : The combined sensitivity and specificity of magnetic resonance for fistula detection were 0.87 (95% CI: 0.63-0.96) and 0.69 (95% CI: 0.51-0.82). There was a high degree of heterogeneity between studies reporting on MRI sensitivity (df = 3, I = 93%). This compares to a sensitivity and specificity for endoanal ultrasound of 0.87 (95% CI: 0.70-0.95) and 0.43 (95% CI: 0.21-0.69). There was a high degree of heterogeneity between studies reporting on endoanal ultrasound sensitivity (df = 3, I = 92%).

CONCLUSIONS: : From the available literature, the summarized performance characteristics for MRI and endoanal ultrasound demonstrate comparable sensitivities at detecting perianal fistulas, although the specificity for MRI was higher than that for endoanal ultrasound. Both specificity values are considered to be diagnostically poor, however. The high degree of data heterogeneity and the shortage of applicable studies precludes any firm conclusions being made for clinical practice. Future trials with improved study design (including prospective data collection and consideration of verification bias) may help to further clarify the role of MRI in the assessment and treatment response monitoring of perianal fistulas (particularly in patients with Crohn’s disease).

PMID: 22513437 [PubMed - in process]

Economic cost of fecal incontinence.

Dis Colon Rectum. 2012 May;55(5):586-98

Authors: Xu X, Menees SB, Zochowski MK, Fenner DE

Abstract

BACKGROUND: : Despite its prevalence and deleterious impact on patients and families, fecal incontinence remains an understudied condition. Few data are available on its economic burden in the United States.

OBJECTIVE: : The aim of this study was to quantify per patient annual economic costs associated with fecal incontinence.

DESIGN: : A mail survey of patients with fecal incontinence was conducted in 2010 to collect information on their sociodemographic characteristics, fecal incontinence symptoms, and utilization of medical and nonmedical resources for fecal incontinence. The analysis was conducted from a societal perspective and included both direct and indirect (ie, productivity loss) costs. Unit costs were determined based on standard Medicare reimbursement rates, national average wholesale prices of medications, and estimates from other relevant sources. All cost estimates were reported in 2010 US dollars.

SETTINGS: : This study was conducted at a single tertiary care institution.

PATIENTS: : The analysis included 332 adult patients who had fecal incontinence for more than a year with at least monthly leakage of solid, liquid, or mucous stool.

MAIN OUTCOME MEASURES: : The primary outcome measured was the per patient annual economic costs associated with fecal incontinence.

RESULTS: : The average annual total cost for fecal incontinence was $4110 per person (median = $1594; interquartile range, $517-$5164). Of these costs, direct medical and nonmedical costs averaged $2353 (median, $1176; interquartile range, $294-$2438) and $209 (median, $75; interquartile range, $17-$262), whereas the indirect cost associated with productivity loss averaged $1549 per patient annually (median, $0; interquartile range, $0-$813). Multivariate regression analyses suggested that greater fecal incontinence symptom severity was significantly associated with higher annual direct costs.

LIMITATIONS: : This study was based on patient self-reported data, and the sample was derived from a single institution.

CONCLUSIONS: : Fecal incontinence is associated with substantial economic cost, calling for more attention to the prevention and effective management of this condition.

PMID: 22513438 [PubMed - in process]

Bowel habits and fecal incontinence in patients with obesity undergoing evaluation for weight loss: the importance of stool consistency.

Dis Colon Rectum. 2012 May;55(5):599-604

Authors: Parés D, Vallverdú H, Monroy G, Amigo P, Romagosa C, Toral M, Hermoso J, Saenz-de-Navarrete G

Abstract

BACKGROUND: : Fecal incontinence is highly prevalent in the general population and especially in risk groups. Obesity is also common and is associated with comorbidities that impair general health and interfere with daily activities. Identifying mutable factors for fecal incontinence, such as stool consistency, is of paramount importance to improve quality of life.

OBJECTIVE: : The aim of this study was to estimate the prevalence of fecal incontinence in patients with obesity undergoing evaluation for weight loss, its relationship with bowel habits, and its impact on quality of life.

DESIGN: : This investigation is a cross-sectional observational study.

SETTINGS: : This study was conducted in patients with obesity who were undergoing evaluation for weight loss.

MAIN OUTCOME MEASURES: : Fecal incontinence was defined as loss of flatus or liquid/solid stool occurring at least monthly. Data on comorbidities, BMI, quality of life, bowel habits including stool consistency measured with the Bristol Stool Form Scale, and symptoms of fecal incontinence were collected.

RESULTS: : Fifty-two patients were included, with a mean BMI of 39.6 kg/m2. Symptoms of fecal incontinence were found in 17 patients (32.7%): flatus in 9 of 17 (52.9%), liquid stool in 6 of 17 (35.2%), and solid stool in 2 of 17 (11.7%). No differences were found between patients with and without fecal incontinence in age, sex, comorbidities, or BMI. Health-related quality of life was lower in patients with fecal incontinence than in those without, but this difference was not significant, with the exception of the dimensions of role-physical (p = 0.03) and social functioning (p = 0.04). Patients with incontinence reported significantly higher percentages of altered bowel habits with nonformed stools (p = 0.004).

LIMITATIONS: : The cross-sectional design hampered identification of the time at which the impact of obesity occurred.

CONCLUSIONS: : Fecal incontinence is common in patients with obesity. Stool consistency was significantly different in these patients. This study supports the possibility of improving incontinence during weight loss by modifying stool consistency.

PMID: 22513439 [PubMed - in process]

Radiofrequency Treatment for Fecal Incontinence: Is It Effective Long-term?

Dis Colon Rectum. 2012 May;55(5):605-10

Authors: Abbas MA, Tam MS, Chun LJ

Abstract

OBJECTIVE: : The aim of this study was to evaluate the short- and long-term outcome of the radiofrequency treatment for moderate to severe fecal incontinence.

DESIGN: : This study is a retrospective review of a single-institution experience.

PATIENTS: : Patients who underwent the radiofrequency procedure were included.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the complication rate, short- and long-term response, and the rate of subsequent intervention for incontinence.

RESULTS: : Twenty-seven patients underwent 31 radiofrequency procedures (81% women; mean age, 64 years). Median length of symptoms was 3 years. Biofeedback had failed for 52% of patients, and 23% of patients had previous surgical intervention. Thirty-eight percent of patients had a sphincter defect. Minor complications were observed in 19% of the patients. A treatment response was noted in 78% of the patients (mean Cleveland Clinic Florida Fecal Incontinence Score: 16 (baseline) and 10.9 (3 months postoperatively)). However, a sustained long-term response without any additional intervention was noted in 22% of the patients, and 52% of the patients underwent or are awaiting additional intervention for persistent or recurrent incontinence (mean follow-up, 40 months).

LIMITATION: : This study is limited by its retrospective nature and the limited number of subjects.

CONCLUSIONS: : The radiofrequency procedure was safe, but a long-term benefit was noted in a minority of patients with moderate to severe fecal incontinence. Additional interventions were required in more than half of the patients. Larger studies are needed to determine the impact of various patient-related factors on the outcome of the radiofrequency treatment to identify the ideal patient for this therapy.

PMID: 22513440 [PubMed - in process]

A Meta-analysis of the Effectiveness of the Opioid Receptor Antagonist Alvimopan in Reducing Hospital Length of Stay and Time to GI Recovery in Patients Enrolled in a Standardized Accelerated Recovery Program After Abdominal Surgery.

Dis Colon Rectum. 2012 May;55(5):611-20

Authors: Vaughan-Shaw PG, Fecher IC, Harris S, Knight JS

Abstract

BACKGROUND: : Despite accelerated recovery programs and the widespread uptake of laparoscopic surgery, postoperative ileus remains a significant factor affecting length of stay after abdominal surgery. Alvimopan, an opioid-receptor antagonist, may reduce the incidence of postoperative ileus and expedite hospital discharge.

OBJECTIVE: : The aim of this study was to perform a meta-analysis to determine the role of alvimopan in accelerating GI recovery and hospital discharge after laparoscopic and open abdominal surgery performed within an accelerated recovery program.

DATA SOURCES AND STUDY SELECTION: : Cochrane (1999-2010), Embase (1980-2010), MEDLINE (1980-2010), and International Pharmaceutical Abstracts (1970-2010) were searched for relevant double-blinded, randomized controlled trials.

INTERVENTIONS: : Twelve milligrams of alvimopan and placebo were given to patients enrolled in an accelerated recovery program after abdominal surgery.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the length of stay as defined by the writing of the hospital discharge order and GI-3 and GI-2 GI tract recovery.

RESULTS: : Three trials were included that reported on a pooled modified intention-to-treat population of 1388 patients; 685 (49%) patients received alvimopan. On meta-analysis, alvimopan reduced time to the hospital discharge order (HR 1.37 (1.21, 1.62), p < 0.0001), GI-3 recovery (HR 1.42 (1.25, 1.62), p < 0.001), and GI-2 recovery (HR 1.49 (1.32, 1.68), p < 0.0001).

LIMITATIONS: : The search criteria identified only a small number of trials of alvimopan after abdominal surgery with no randomized trials of alvimopan after laparoscopic surgery. In addition, the use of length of hospital stay as the primary outcome measure may be inappropriate, because it is open to many confounding factors. Finally, adverse events, in particular, adverse cardiovascular events, were not considered.

CONCLUSIONS: : Alvimopan 12 mg can further reduce time to GI recovery and hospital discharge in patients undergoing abdominal surgery within an accelerated recovery program. Investigation into the effect of alvimopan following laparoscopic surgery and additional cost-benefit analyses are required to further define the role of this intervention.

PMID: 22513441 [PubMed - in process]

Sacral nerve stimulation for fecal incontinence: at a crossroad and future challenges.

Dis Colon Rectum. 2012 May;55(5):621-4

Authors: Maeda Y, O’Connell PR, Matzel KE, Laurberg S

PMID: 22513442 [PubMed - in process]

Is the placement of the new synthetic anal fistula plug really so ineffective?

Dis Colon Rectum. 2012 May;55(5):e61

Authors: Ratto C, Litta F, Parello A, Donisi L

PMID: 22513443 [PubMed - in process]

The author replies.

Dis Colon Rectum. 2012 May;55(5):e61-2

Authors: de la Portilla F

PMID: 22513444 [PubMed - in process]

Self-assessment quiz: answers, critiques, and references.

Dis Colon Rectum. 2012 May;55(5):e63-4

Authors: Margolin DA

PMID: 22513445 [PubMed - in process]

Selected abstracts.

Dis Colon Rectum. 2012 May;55(5):e65-70

Authors: Cirocco WC

PMID: 22513446 [PubMed - in process]

Announcements.

Dis Colon Rectum. 2012 May;55(5):e71

Authors:

PMID: 22513447 [PubMed - in process]

Residency programs in colon and rectal surgery.

Dis Colon Rectum. 2012 May;55(5):e72-4

Authors:

PMID: 22513448 [PubMed - in process]

Surgical genomics: using new technology to answer age-old questions.

Dis Colon Rectum. 2012 Feb;55(2):113-4

Authors: Kennedy GD

PMID: 22228151 [PubMed - indexed for MEDLINE]

Single-port laparoscopic right hemicolectomy: the first 100 resections.

Dis Colon Rectum. 2012 Feb;55(2):134-9

Authors: Waters JA, Rapp BM, Guzman MJ, Jester AL, Selzer DJ, Robb BW, Johansen BJ, Tsai BM, Maun DC, George VV

Abstract

BACKGROUND: Single-port laparoscopy remains a novel technique in the field of colorectal surgery. Several small series have examined its safety for colon resection.

OBJECTIVE: Our aim was to analyze our entire experience and short-term outcomes with single-port laparoscopic right hemicolectomy since its introduction at our institution. We assert that this approach is feasible and safe for the wide array of patients and indications encountered by a colorectal surgeon.

DESIGN: This is a retrospective analysis of prospectively gathered data for all patients who underwent single-port laparoscopic right hemicolectomy with the use of standard laparoscopic instrumentation, for malignant or benign disease, between July 2009 and November 2010 in a high-volume, academic, colorectal surgery practice.

MAIN OUTCOME MEASURES: Demographic, clinical, operative, and pathologic factors were reviewed and analyzed. All conversions to conventional laparoscopic or open operations were considered in this analysis.

RESULTS: One hundred patients underwent single-port laparoscopic right hemicolectomy during the study period. Mean age was 63 years, and 61% of the patients were men. Forty-three percent had undergone previous abdominal surgery, and the median body mass index was 26 (range, 18-46). Median ASA classification was 3 (range, 1-4). Five percent of the operations were performed urgently, and 56% were performed for carcinoma, of which half were T3 or T4 tumor stage. Median operative duration was 105 (range, 64-270) minutes. Mean and median blood loss was 106 and 50 mL. Two percent required conversion to multiport laparoscopy, and 4% converted to the open approach. Median postoperative stay was 4 (range, 2-48) days. Median lymph node number was 18 (range, 11-42). There was one mortality in this series. Morbidity, including wound infection, was 13%.

CONCLUSIONS: This represents the largest experience with single-port laparoscopic right hemicolectomy to date. This technique was used with acceptable morbidity and mortality and without compromise of conventional oncologic parameters by colorectal surgeons experienced in minimally invasive technique. These findings support the use of a single-port approach for patients requiring right hemicolectomy.

PMID: 22228155 [PubMed - indexed for MEDLINE]

T-pouch: results of the first 10 years with a nonintussuscepting continent ileostomy.

Dis Colon Rectum. 2012 Feb;55(2):155-62

Authors: Kaiser AM

Abstract

BACKGROUND: Continent ileostomy is an alternative for patients who are either not candidates for an ileo-anal pullthrough or in whom an ileo-anal pullthrough failed. We previously described a new type of continent ileostomy (T-pouch) with a nonintussuscepting valve.

OBJECTIVE: This study performed an outcomes analysis of the first 10 years with 40 patients.

DESIGN: A prospective database of patients with a T-pouch from 2000 to 2010 was retrospectively analyzed.

MAIN OUTCOME MEASURES: The primary outcomes measured were demographics and surgical recovery information and the functional data obtained via questionnaire: incontinence, difficulty of pouch intubation, restrictions (work, social, diet, and sexual), quality of health and life, and level of satisfaction with surgery, which were rated on a scale of 0 to 10.

RESULTS: Twenty-three women and 17 men (mean age, 51.2) received a T-pouch. Median follow-up was 6.2 years (range, 0.8-11 years). Five patients (12.5%) experience a leak; 3 leaks were managed conservatively and/or with drain placement. Pouch intubations were done 4 times per day in a mean of 6.8 minutes; the insertion difficulty was rated as 2.5 of 10. Ninety-two percent achieved good continence. All quality-of-life and dysfunction/restriction scores showed significant improvement. Major abdominal surgeries for pouch-related reasons were needed in 30%; minor service operations of the skin-level stoma were needed in 25% of the patients. Of the patients, 87.5% would do the surgery again; 90% would recommend it to others with the same diagnosis.

LIMITATIONS: This study was limited by the cohort size and the lack of long-term data.

CONCLUSION: Ten years with 40 patients confirmed that creation of a T-pouch is complex but could be performed with an acceptable rate of complications. It dramatically improved functional outcomes; most notably, it improved fecal control and decreased social, sexual, and work restrictions.

PMID: 22228158 [PubMed - indexed for MEDLINE]

Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure.

Dis Colon Rectum. 2012 Feb;55(2):167-74

Authors: Chun LJ, Haigh PI, Tam MS, Abbas MA

Abstract

OBJECTIVE: The aim of this study was to determine the morbidity of a defunctioning loop ileostomy and the subsequent closure rate, and to identify the predictors of complications and nonclosure of stoma.

DESIGN: This study is a retrospective review of a single-institution experience.

PATIENTS: All patients who underwent a planned temporary defunctioning loop ileostomy performed synchronously with a pelvic anastomosis during a 6-year period were included.

MAIN OUTCOME MEASURES: The primary outcome measures were the ileostomy complication rate for the entire spectrum of care, readmission and reoperation rates to treat ileostomy complications, and subsequent closure rate. Patient and treatment factors were evaluated for their independent effect on complications and closure rate with the use of multivariable logistic regression.

RESULTS: One hundred twenty-three patients were identified (median age, 51 years). Of these patients, 64.2% developed ≥1 minor or major ileostomy complications (13.8% during index hospitalization, 52.8% as outpatient, and 23.4% after closure). Readmitted for dehydration following ileostomy formation were 11.4% of patients. The ileostomy was closed in 76.4% of patients with 8.6% requiring a midline laparotomy. The overall ileostomy-related reoperation rate was 10.4% (2.4% during index hospitalization, 1.6% at readmission, and 6.4% following ileostomy closure). Obesity (BMI ≥30 kg/m) was associated with a higher overall ileostomy complication rate (OR 8.56, 95% CI 1.64-44.74) and outpatient complication rate (OR 7.69, 95% CI 2.48-23.81). Age >65 years (OR 53.34, 95% CI 4.21-676.14) and hypertension (OR 8.36, 95% CI 1.09-64.43) increased the risks of high ileostomy output and dehydration. Obesity (OR 4.61, 95% CI 1.14-18.54) and smoking (4.47, 95% CI 1.43-13.98) decreased the likelihood of ileostomy closure.

LIMITATION: This study was limited by its retrospective nature.

CONCLUSIONS: The morbidity of a defunctioning loop ileostomy remains significant. Obesity is an independent predictor of ileostomy complications. Older age and hypertension increase the risks of high-output stoma and dehydration. Almost one quarter of patients never have the ileostomy closed. Obesity and smoking are associated with less likelihood of a subsequent ileostomy closure.

PMID: 22228160 [PubMed - indexed for MEDLINE]

Clinicopathologic and molecular characteristics of synchronous colorectal cancers: heterogeneity of clinical outcome depending on microsatellite instability status of individual tumors.

Dis Colon Rectum. 2012 Feb;55(2):181-90

Authors: Bae JM, Cho NY, Kim TY, Kang GH

Abstract

BACKGROUND: The contribution of chromosomal instability, microsatellite instability, and epigenetic instability to the development of synchronous colorectal carcinomas is controversial.

OBJECTIVE: This study aimed to investigate the relative roles of microsatellite instability and epigenetic instability in the development of synchronous colorectal cancers.

DESIGN: This was a retrospective study of medical records with histologic, immunohistochemical, and molecular examination of stored tissue samples.

SETTING: The study took place at Seoul National University Hospital, Korea.

PATIENTS: A total of 46 patients with synchronous colorectal cancers and 105 patients with solitary colorectal cancers were included.

MAIN OUTCOME MEASURES: Clinicopathologic and molecular characteristics including microsatellite instability, mismatch repair gene expression, CpG island methylator phenotype, and mutation of KRAS and BRAF were analyzed.

RESULTS: Patients with synchronous tumors were more likely to be men than those with solitary tumors and had a tendency toward colocalization of individual tumors in the left or right colon. MSI-deficient cancers were more frequent in synchronous than in solitary cancers. The frequencies of CpG island methylator phenotype-high and KRAS and BRAF mutations were not different between synchronous and solitary cancers. No differences between synchronous cancers and solitary cancers were observed in overall survival or progression-free survival. Within the synchronous cancer group, patients with individual tumors discordant for microsatellite instability status had the worst clinical outcome, whereas those with individual tumors concordant for microsatellite instability-deficient status had the best clinical outcome.

LIMITATIONS: The study was limited by its retrospective nature. Molecular analysis was performed only on cancerous lesions.

CONCLUSIONS: Our findings suggest that microsatellite instability plays a more important role than does epigenetic instability in the development of synchronous colorectal cancers, and that information regarding concordant or discordant microsatellite instability status between individual tumors might help to predict clinical outcome of synchronous colorectal cancers.

PMID: 22228162 [PubMed - indexed for MEDLINE]

Pathological evaluation of mesocolic resection quality and ex vivo methylene blue injection: what is the impact on lymph node harvest after colon resection for cancer?

Dis Colon Rectum. 2012 Feb;55(2):197-204

Authors: Frasson M, Faus C, Garcia-Granero A, Puga R, Flor-Lorente B, Cervantes A, Navarro S, Garcia-Granero E

Abstract

BACKGROUND: Although the National Quality Forum has endorsed the harvest of ≥12 lymph nodes as a standard quality indicator for colon cancer surgery, this minimum quantity is not reached in many centers.

OBJECTIVE: The aim of this study was to assess the impact of the implementation of a mesocolon evaluation pathological protocol and ex vivo arterial methylene blue injection on the number of nodes harvested after colon cancer resection.

DESIGN: A prospective series was compared with a historical group.

SETTINGS: This study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital.

PATIENTS: From June 2009 to December 2009, all the specimens after colon resection for cancer were analyzed with the use of a “mesocolon quality pathological evaluation” protocol. Moreover, a consecutive series of specimens was analyzed after arterial ex vivo injection of methylene blue. We compared the study groups with our previous series (2005-2009).

INTERVENTIONS: The “mesocolon quality pathological evaluation” protocol was used with or without arterial methylene blue ex vivo injection.

MAIN OUTCOME MEASURE: The primary outcome measure was the number of lymph nodes harvested.

RESULTS: The mean number (SD) of lymph nodes collected was 20.6 (10.5), 37.1 (12.8), and 47.6 (12.9) (p < 0.0001) in the control, protocol, and methylene blue groups. In the control group, the minimum number of 12 and 18 lymph nodes collected was not reached in 92 (15.9%) and 258 (44.6%) patients. In contrast, all patients in the protocol and methylene blue groups had more than 18 lymph nodes collected. The multivariate analysis confirmed the application of the “mesocolon quality pathological evaluation” protocol and the methylene blue ex vivo injection, along with the type of resection and the length of the specimen, to be independent factors determining the number of nodes collected.

LIMITATIONS: The patients are not randomly selected and are compared with a retrospective series.

CONCLUSION: The implementation of a “mesocolon quality pathological evaluation” protocol along with the arterial ex vivo injection of methylene blue can significantly increase the number of nodes isolated after colonic resection, reaching a 100% rate of specimens with more than 12 nodes.

PMID: 22228164 [PubMed - indexed for MEDLINE]

Viscoelastic assessment of anal canal function using acoustic reflectometry: a clinically useful technique.

Dis Colon Rectum. 2012 Feb;55(2):211-7

Authors: Mitchell PJ, Klarskov N, Telford KJ, Hosker GL, Lose G, Kiff ES

Abstract

BACKGROUND: Anal acoustic reflectometry is a new reproducible technique that allows a viscoelastic assessment of anal canal function. Five new variables reflecting anal canal function are measured: the opening and closing pressure, opening and closing elastance, and hysteresis.

OBJECTIVE: The aim of this study was to assess whether the parameters measured in anal acoustic reflectometry are clinically valid between continent and fecally incontinent subjects.

DESIGN: This was an age- and sex-matched study of continent and incontinent women.

SETTING: The study was conducted at a university teaching hospital.

PATIENTS: One hundred women (50 with fecal incontinence and 50 with normal bowel control) were included in the study. Subjects were age matched to within 5 years.

MAIN OUTCOME MEASURES: Parameters measured with anal acoustic reflectometry and manometry were compared between incontinent and continent groups using a paired t test. Diagnostic accuracy was assessed by the use of receiver operator characteristic curves.

RESULTS: Four of the 5 anal acoustic reflectometry parameters at rest were significantly different between continent and incontinent women (eg, opening pressure in fecally incontinent subjects was 31.6 vs 51.5 cm H2O in continent subjects, p = 0.0001). Both anal acoustic reflectometry parameters of squeeze opening pressure and squeeze opening elastance were significantly reduced in the incontinent women compared with continent women (50 vs 99.1 cm H2O, p = 0.0001 and 1.48 vs 1.83 cm H2O/mm, p = 0.012). In terms of diagnostic accuracy, opening pressure at rest measured by reflectometry was significantly superior in discriminating between continent and incontinent women in comparison with resting pressure measured with manometry (p = 0.009).

CONCLUSIONS: Anal acoustic reflectometry is a new, clinically valid technique in the assessment of continent and incontinent subjects. This technique, which assesses the response of the anal canal to distension and relaxation, provides a detailed viscoelastic assessment of anal canal function. This technique may not only aid the investigation of fecally incontinent subjects, but it may also improve our understanding of anal canal physiology during both the process of defecation and maintenance of continence.

PMID: 22228166 [PubMed - indexed for MEDLINE]

CT scans in diagnosing diverticulitis in the emergency department: is the radiation exposure warranted?

Dis Colon Rectum. 2012 Feb;55(2):226-7

Authors: Lutwak N, Dill C

PMID: 22228168 [PubMed - indexed for MEDLINE]

Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: a multicenter study.

Dis Colon Rectum. 2012 Jan;55(1):42-50

Authors: McKay GD, Morgan MJ, Wong SK, Gatenby AH, Fulham SB, Ahmed KW, Toh JW, Hanna M, Hitos K,

Abstract

BACKGROUND: Evidence demonstrates short-term benefits of laparoscopic surgery for colon cancer. The situation for rectal cancer is less clear.

OBJECTIVES: This review assessed the use and short-term outcomes of elective open and laparoscopic colon and rectal cancer resections within an area health service.

DESIGN: This was a multicenter, retrospective review of a prospective database.

SETTINGS: All elective colon and rectal cancer resections in the western zone of Sydney South West Area Health Service from 2001 until 2008 were included.

PATIENTS: Included were 1721 patients who underwent either a laparoscopic colon (n = 434) or rectal (n = 157) resection or an open colon (n = 742) or rectal (n = 388) resection.

MAIN OUTCOME MEASURES: : Outcome measures included operating time, blood loss, adequacy of resection, conversion rate, intensive care unit admission, length of stay, and 26 acute postoperative complications.

RESULTS: Patients were matched for age, sex, ASA, BMI, and tumor stage. Laparoscopic surgery increased in frequency. Fewer patients experienced a complication in both the laparoscopic colon (28.8 vs 54.4%; p < 0.0001) and rectal (41.4 vs 60.3%; p < 0.0001) group irrespective of age. Laparoscopic operating time for colon and rectal cancer was 24.1 minutes (p < 0.0001) and 25.8 minutes (p < 0.0001) longer, with a low conversion-to-open rate (6.5% and 8.3%; p = 0.44). Laparoscopic surgery resulted in fewer transfusions (0.4 vs 0.7 units; p = 0.0028) and length of stay (7 vs 10 days; p = 0.0011) for colon cancers, and reduced intraoperative hemoglobin drop (20.5 vs 24.8; p = 0.029) and intensive care unit admissions (26.8 vs 36.3%; p = 0.032) for rectal cancers.

LIMITATIONS: : This was a nonrandomized study with rectal cancers more often resected with the open technique (71.2 vs 28.8%; p < 0.001).

CONCLUSIONS: Within an area health service, elective laparoscopic resection for colon and rectal cancer had improved short-term outcomes in comparison with open surgery.

PMID: 22156866 [PubMed - indexed for MEDLINE]

Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study.

Dis Colon Rectum. 2012 Jan;55(1):e3; author reply e3-4

Authors: Inusah S, Davis TD, Albright KC, McGwin G

PMID: 22156879 [PubMed - indexed for MEDLINE]

Mutations in IRGM Are Associated With More Frequent Need for Surgery in Patients With Ileocolonic Crohn’s Disease.

Dis Colon Rectum. 2012 Feb;55(2):115-21

Authors: Sehgal R, Berg A, Polinski JI, Hegarty JP, Lin Z, McKenna KJ, Stewart DB, Poritz LS, Koltun WA

Abstract

BACKGROUND: : There are no clear criteria for judging the severity of disease in patients with Crohn’s disease. Yet classification of patients into low- and high-risk severity groups would benefit both medical and surgical management. At the time of this study, approximately 80 single-nucleotide polymorphisms within 55 genes had been associated with IBD.

OBJECTIVE: : The aim of this study was to identify genetic determinants (single-nucleotide polymorphisms) that could be markers of Crohn’s disease severity by the use of frequency of ileocolic surgery as a surrogate for disease severity.

DESIGN: : Sixty-six patients (30 male) with ileocolonic Crohn’s disease who previously underwent ileocolectomy were retrospectively studied. The severity of Crohn’s disease was quantified by dividing the total number of ileocolectomy procedures by the time between IBD diagnosis and the patient’s last clinic visit, the rationale being that more severe disease would be associated with a more frequent need for surgery. Genotyping for the 83 single-nucleotide polymorphisms associated with IBD was done on a customized Illumina Veracode genotyping platform. Three genetic models (general, additive, and dominant) were used to statistically quantify the genetic association of the studied single-nucleotide polymorphisms to the frequency of surgery after adjusting for covariates (age, smoking, family history, disease location, and disease behavior).

RESULTS: : For the entire group the average number of ileocolectomies per patient was 1.7 (range, 1-5) with an average duration of disease of 14.7 years. Single-nucleotide polymorphism rs4958847 in the IRGM gene (immunity-related GTPase family, M) was the most significant single-nucleotide polymorphism in all 3 models tested (p = 0.007) as being associated with ileocolectomy, and it remained significant even after a Benjamini-Hochberg false-discovery correction for multiple observations. Patients carrying the “at-risk” allele for this single-nucleotide polymorphism (n = 20) had an average of 1 surgery every 6.87 ± 1.33 years in comparison with patients carrying the wild-type genotype (n = 46) who averaged 1 surgery in 11.43 ± 1.21 years (p = 0.007, Mann-Whitney U test).

CONCLUSIONS: : Single-nucleotide polymorphism rs4958847 in the IRGM gene correlated very significantly with frequency of surgery in patients with ileocolonic Crohn’s disease. IRGM is a mediator of innate immune responses and is involved in autophagy. The presence of this IRGM SNP may be a marker for disease severity and/or early recurrence after ileocolectomy and may assist in surgical and medical decision making.

PMID: 22228152 [PubMed - in process]

Rate of residual disease after complete endoscopic resection of malignant colonic polyp.

Dis Colon Rectum. 2012 Feb;55(2):122-7

Authors: Butte JM, Tang P, Gonen M, Shia J, Schattner M, Nash GM, Temple LK, Weiser MR

Abstract

BACKGROUND: : Following polypectomy, colectomy is performed selectively to ensure complete clearance of neoplasia.

OBJECTIVE: : This study aimed to determine the risk factors associated with residual disease at colectomy following malignant polypectomy.

DESIGN: : This is a retrospective study.

SETTING: : This investigation took place at a tertiary teaching cancer center.

PATIENTS: : Consecutive patients undergoing polypectomy followed by colectomy from 1990 to 2007 were identified from a prospective database.

MAIN OUTCOME MEASURES: : Factors associated with residual disease at colectomy were associated with clinicopathologic features.

RESULTS: : Colectomy following polypectomy was performed in 143 patients: 127 with clear invasion of polyp submucosa (invasive disease), and 16 suspicious for submucosal invasion. Residual disease after colectomy was diagnosed in 27 (19%) of 143 patients. Disease was present in the colonic wall in 19 patients (13%): invasive in 16 (11%), and noninvasive in 3 (2.1%). Of the 16 patients with residual invasive disease at colectomy, 15 had clearly invasive disease at polypectomy and 1 was suspicious for invasive disease at polypectomy. Lymph node metastasis was noted in 10 (7.0%) patients. When analyzing patients with clearly invasive disease at polypectomy by margin status, residual invasive disease in the colon wall was noted in 8 of 50 (16%) with <1 mm (positive) polypectomy margin, 7 of 33 (21%) with indeterminate polypectomy margin, and 0 of 44 with ≥1 mm (negative) polypectomy margin (p = 0.009). Nodal metastasis was associated with the presence of lymphovascular invasion (p = 0.01).

LIMITATIONS: : This study is limited by its retrospective nature and selection bias.

CONCLUSIONS: : Following malignant polypectomy, colectomy should be considered in medically fit patients if the polypectomy margin is positive (≤1 mm) or unknown, or if lymphovascular invasion is present.

PMID: 22228153 [PubMed - in process]

BRAF Mutations in Colorectal Cancer Are Associated With Distinct Clinical Characteristics and Worse Prognosis.

Dis Colon Rectum. 2012 Feb;55(2):128-33

Authors: Kalady MF, Dejulius KL, Sanchez JA, Jarrar A, Liu X, Manilich E, Skacel M, Church JM

Abstract

BACKGROUND: : Colorectal cancer is a heterogeneous disease with multiple underlying genetic mutations causing different clinical phenotypes. Mutation in the BRAF oncogene is a key step in malignant transformation within the methylator pathway to colorectal cancer. However, there is a paucity of information about BRAF mutant colorectal tumors.

OBJECTIVE: : This study defines the clinical characteristics and oncologic outcome associated with colorectal cancer BRAF mutations.

DESIGN: : Colorectal adenocarcinomas from a single-institution frozen-tumor biobank were studied. Genomic DNA was isolated and analyzed for mutations in the BRAF oncogene by polymerase chain reaction amplification followed by direct sequencing. A sample was classified as mutant if any of the tested loci were mutated. Patient and tumor characteristics were recorded including patient age, sex, tumor location, tumor differentiation, and microsatellite instability.

MAIN OUTCOME MEASURES: : Statistical associations with BRAF mutant tumors were determined by the Fisher exact probability test, χ test, or Wilcoxon analysis. Kaplan-Meier estimates and multivariate Cox regression analysis were performed for overall survival.

RESULTS: : Four hundred seventy-five colorectal adenocarcinomas were included in the study population; 56 samples harbored a BRAF mutation (12%). There were significant differences between BRAF wild-type and mutant tumors in age (66 vs 75 years, p = 0.004), female sex (44% vs 71%, p < 0.001), proximal tumor location (44% vs 95%, p < 0.001), and frequency of microsatellite instability (16% vs 76%, p < 0.001). There was no difference in cancer stage between BRAF mutant and wild-type populations. Survival data were analyzed for 322 patients with stage I to III disease, and patients with a BRAF mutation had decreased overall survival than those without a mutation (p = 0.018). With the use of Cox regression analysis, BRAF mutation conferred a worse overall survival (HR 1.79, CI 1.05-3.05, p = 0.03) independent of microsatellite instability status.

CONCLUSIONS: : BRAF mutations in colorectal cancers are associated with distinct clinical characteristics and worse prognosis.

PMID: 22228154 [PubMed - in process]

Single-incision laparoscopic surgery for ileocolic resection in Crohn’s disease.

Dis Colon Rectum. 2012 Feb;55(2):140-6

Authors: Rijcken E, Mennigen R, Argyris I, Senninger N, Bruewer M

Abstract

BACKGROUND: : Single-incision laparoscopic surgery is a development in the field of minimally invasive surgery that is being increasingly used for colorectal procedures.

OBJECTIVE: : We report on the short-term results of single-port laparoscopic ileocolic resection in patients with ileocecal Crohn’s disease.

DESIGN: : This investigation is a retrospective matched-pair control study. Data were obtained from a prospectively maintained single-institution inflammatory bowel disease database.

SETTINGS: : This study was conducted at a tertiary care university hospital.

PATIENTS: : Twenty consecutive patients receiving elective single-port ileocolic resection between April 2010 and May 2011 were included (6 male, 14 female; age, 31.6 ± 10.8 years; BMI, 21.5 ± 2.6 kg/m). Their data were compared with the data of 20 individually matched patients who had undergone standard 3-trocar laparoscopic-assisted ileocolic resection between 2007 and 2010 (6 male, 14 female; age, 31.7 ± 10.7 years; BMI, 21.2 ± 2.5 kg/m). All patients had medically refractory stenosis of the terminal ileum in histologically confirmed Crohn’s disease.

INTERVENTIONS: : Single-port laparoscopic-assisted or standard laparoscopic-assisted ileocolic resection was performed.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the surgical details and early outcome.

RESULTS: : The mean length of the paraumbilical single-port incision was 3.8 cm (range, 2.5-5.0 cm). Conversion rates were similar in both groups (1/20 vs 2/20, p = 0.55). Additional strictureplasties or short-segment small-bowel resections were performed in both groups. The overall complication rate was 20% (4/20) in both groups. There were no observed differences in postoperative pain scores and hospital stay duration.

LIMITATIONS: : The limitations of this study were as follows: this study was a comparison of 2 different time points with possible selection bias, there was no prestudy power calculation, and the study might be underpowered.

CONCLUSIONS: : Single-port ileocolic resection is a safe procedure for the surgical treatment of stenotizing Crohn’s disease of the terminal ileum. Avoidance of additional trocars was the only identified benefit.

PMID: 22228156 [PubMed - in process]

Long-term Quality of Life and Sexual and Urinary Function After Abdominoperineal Resection for Distal Rectal Cancer.

Dis Colon Rectum. 2012 Feb;55(2):147-54

Authors: Kasparek MS, Hassan I, Cima RR, Larson DR, Gullerud RE, Wolff BG

Abstract

BACKGROUND: : Permanent colostomy, pelvic dissection, and radiotherapy after abdominoperineal resection can put quality of life and sexual and urinary function at risk; however, there are limited data using validated instruments on patients undergoing abdominoperineal resection regarding these outcome measures.

OBJECTIVE: : We evaluated the quality of life and the sexual and urinary function of patients undergoing abdominoperineal resection for rectal cancer and compared the outcomes of patients who received and did not receive pre- or postoperative pelvic radiotherapy.

METHODS: : European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR38, International Consultation on Incontinence Questionnaire, American Urological Association Symptom Index, Brief Sexual Function Inventory for men, and sexual function module of the Cancer Rehabilitation Evaluation System for women were mailed to 219 patients who underwent abdominoperineal resection between 1994 and 2004.

RESULTS: : One-hundred forty-three patients responded (response rate, 65%), of whom 55 (38%) were treated with surgery alone and 88 (62%) received pelvic radiotherapy. Generic and disease-specific quality of life and sexual and urinary function were similar between patients not receiving and receiving pelvic radiotherapy. However, a proportion of patients experienced adverse quality of life after surgery, and this was associated with a younger age, male sex, and sexual inactivity. In sexually active men, sexual function after abdominoperineal resection was diminished compared with population-based controls.

LIMITATIONS: : This study was limited by the lack of baseline data and cross-sectional nature of survey.

CONCLUSIONS: : Quality of life and sexual function can be impaired after abdominoperineal resection, although the impact of pelvic radiotherapy appears to be limited. Indication and timing of radiotherapy should be based on oncological indications, but quality of life and functional outcomes should be considered when counseling patients.

PMID: 22228157 [PubMed - in process]

Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract?

Dis Colon Rectum. 2012 Feb;55(2):163-6

Authors: van Onkelen RS, Gosselink MP, Schouten WR

Abstract

BACKGROUND: : Transanal advancement flap repair is successful in 2 of every 3 patients with a cryptoglandular fistula passing through the middle or upper third of the external anal sphincter. It has been suggested that ongoing disease in the remaining fistula tract contributes to failure. Ligation of the intersphincteric fistula tract might be a useful tool to eradicate this ongoing disease.

OBJECTIVE: : The aim of the present study was to evaluate the effect of an additional ligation of the fistula tract on the outcome of transanal advancement flap repair.

DESIGN: : This investigation was designed as a prospective clinical study.

SETTINGS: : The study took place in a university hospital.

PATIENTS: : A consecutive series of 41 patients with a high transsphincteric fistula of cryptoglandular origin were included.

INTERVENTION: : Ligation of the intersphincteric fistula tract was performed in addition to flap repair.

MAIN OUTCOME MEASURES: : Early and late complications were recorded. Continence scores were determined with the use of the Fecal Incontinence Severity Index.

RESULTS: : Median duration of follow-up was 15 months. Primary healing was observed in 21 patients (51%). Of the 20 patients with a failure, the original transsphincteric fistula persisted in 12 patients. In 8 patients, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulectomy, which was successful in all of them. The overall healing rate was 71%.

LIMITATIONS: : This was a preliminary observational study with no control group.

CONCLUSIONS: : The ligation of the intersphincteric fistula tract procedure is prone to infection and does not enhance the outcome of flap repair.

PMID: 22228159 [PubMed - in process]

Dehydration is the most common indication for readmission after diverting ileostomy creation.

Dis Colon Rectum. 2012 Feb;55(2):175-80

Authors: Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, Poritz LS

Abstract

BACKGROUND: : Early readmission after discharge from the hospital is an undesirable outcome. Ileostomies are commonly used to prevent symptomatic anastomotic complications in colorectal resections.

OBJECTIVE: : The aim of this study was to identify factors predictive of readmission after colectomy/proctectomy and diverting loop ileostomy.

DESIGN: : This study is a retrospective review.

PATIENTS: : Patients were included who underwent colon and rectal resections with ileostomy at our institution. Sex, age, type of disease, comorbidities, elective vs urgent procedure, type of ileostomy, operative method, steroid use, ASA score, and the use of diuretics were evaluated as potential factors for readmission.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the need for readmission and the presence of dehydration (ostomy output ≥1500 mL over 24 hours and a blood urea nitrogen/creatinine level ≥20, or physical findings of dehydration).

RESULTS: : Six hundred three loop ileostomies were created mostly in white (95.3%), male (55.6%) patients undergoing colon or rectal resections. IBD was the most common indication at 50.9%, with rectal cancer at 16.1%, and other at 31.0%. The 60-day readmission rate was 16.9% (n = 102) with the most common cause dehydration (n = 44, 43.1%). Regression analysis demonstrated that the laparoscopic approach (p = 0.02), lack of epidural anesthesia (p = 0.004), preoperative use of steroids (p = 0.04), and postoperative use of diuretics (p = 0.0001) were highly predictive for readmission. Furthermore, regression analysis for readmission for dehydration identified the use of postoperative diuretics as the sole risk factor (p = 0.0001).

LIMITATIONS: : This study is limited by the retrospective analysis of data, and it does not capture patients that were treated at home or in clinic.

CONCLUSION: : Readmission after colon or rectal resection with diverting loop ileostomy was high at 16.9%. Dehydration was the major cause for readmission. Patients receiving diuretics are at increased risk for readmission for dehydration. High-risk patients should be treated more cautiously as inpatients and closely monitored in the outpatient setting to help reduce dehydration and readmission.

PMID: 22228161 [PubMed - in process]

Risk Factors for Rectal Stump Cancer in Inflammatory Bowel Disease.

Dis Colon Rectum. 2012 Feb;55(2):191-196

Authors: Lutgens MW, van Oijen MG, Vleggaar FP, Siersema PD, Broekman MM, Oldenburg B,

Abstract

BACKGROUND:: Patients with long-standing colitis carry an increased risk of colorectal cancer and are therefore enrolled in colonoscopic surveillance programs. It is presently not known if endoscopic surveillance of patients with colitis with a closed rectal stump after a subtotal colectomy is justified. Neither is it clear which of these patients might be at increased risk for rectal stump cancer. OBJECTIVE:: The aim of this study is to identify the risk factors for rectal stump cancer. DESIGN:: This investigation is a retrospective descriptive case-control study. SETTINGS:: This study was conducted at tertiary referral centers in the Netherlands. PATIENTS:: Colorectal cancer cases associated with inflammatory bowel disease diagnosed between 1990 and 2006 were selected in a nationwide pathology archive. Patients with rectal stump cancer were selected from this group. The pathology archive was also used to identify inflammatory bowel disease controls matched for referral center with a closed rectal stump after subtotal colectomy, but without neoplasia. Follow-up started at the date of subtotal colectomy with the formation of a rectal stump. Demographic and disease characteristics were collected at baseline. MAIN OUTCOME MEASUREMENTS:: Hazard ratios with 95% confidence intervals were calculated for factors associated with the development of rectal stump cancer with the use of univariate Cox regression analysis. End points were rectal stump cancer, end of follow-up, or death. RESULTS:: A total of 12 patients with rectal stump cancer and 18 matching controls without neoplasia were identified. Univariate analysis showed an association between rectal stump cancer and primary sclerosing cholangitis, and disease duration until subtotal colectomy. LIMITATIONS:: This study is limited by its retrospective design, and, despite being the largest series to date, it still has a limited number of cases. CONCLUSIONS:: Risk factors for rectal stump cancer in a closed rectal stump after subtotal colectomy were primary sclerosing cholangitis and disease duration until subtotal colectomy.

PMID: 22228163 [PubMed - as supplied by publisher]

Perioperative use of statins in elective colectomy.

Dis Colon Rectum. 2012 Feb;55(2):205-10

Authors: Singh PP, Srinivasa S, Bambarawana S, Lemanu DP, Kahokehr AA, Zargar-Shoshtari K, Hill AG

Abstract

BACKGROUND: : Statins have many beneficial effects and may attenuate the proinflammatory and metabolic stress response to surgery and consequently reduce postoperative morbidity.

OBJECTIVE: : This study investigated whether perioperative use of statins improved short-term outcomes after elective colectomy.

DESIGN: : This study is a retrospective review of prospectively collected data. SETTINGS AND PATIENTS:: This study was conducted in consecutive patients undergoing elective colonic resection within an enhanced recovery program at a tertiary hospital (Manukau Surgery Centre, Middlemore Hospital, Auckland, New Zealand) from January 2005 to December 2010.

MAIN OUTCOME MEASURES: : Complications, hospital stay, and readmissions were recorded for 30 days postoperatively. Postoperative functional recovery was measured by the use of the validated Surgical Recovery Score. Serum proinflammatory cytokines were measured on postoperative day 1.

RESULTS: : There were 269 patients; 86 patients were on a statin perioperatively, whereas 183 patients had no statin. Members of the statin group were older (median age, 72 vs 69 years; p = 0.021), included more men (53% vs 40%; p = 0.049), and included a higher number of patients with an ASA score of 3 (55% vs 22%; p < 0.001). Patients on statin therapy had a significantly lower number of anastomotic leaks (1% vs 7%; p = 0.031). However, there was no significant difference in total complications or median hospital stay. The 2 groups had comparable functional recovery, and there was no significant difference in serum cytokine levels.

LIMITATIONS: : This retrospective study did not analyze type, duration, or dose of statins given perioperatively.

CONCLUSION: : Patients on perioperative statins had greater baseline perioperative risks compared with nonusers, but they achieved equivalent outcomes overall. Statin use was associated with reduced anastomotic leaks. Thus, perioperative statin use may reduce morbidity after elective colectomy, and this finding warrants further investigation.

PMID: 22228165 [PubMed - in process]

Reverse-hybrid robotic mesorectal excision for rectal cancer.

Dis Colon Rectum. 2012 Feb;55(2):228-33

Authors: Park IJ, You YN, Schlette E, Nguyen S, Skibber JM, Rodriguez-Bigas MA, Chang GJ

Abstract

PURPOSE: : The robotic system offers potential technical advantages over laparoscopy for total mesorectal excision with radical lymphadenectomy for rectal cancer. However, the requirement for fixed docking limits its utility when the working volume is large or patient repositioning is required. The purpose of this study was to evaluate short-term outcomes associated with a novel setup to perform total mesorectal excision and radical lymphadenectomy for rectal cancer by the use of a “reverse” hybrid robotic-laparoscopic approach.

METHODS: : This is a prospective consecutive cohort observational study of patients who underwent robotic rectal cancer resection from January 2009 to March 2011. During the study period, a technique of reverse-hybrid robotic-laparoscopic rectal resection with radical lymphadenectomy was developed. This technique involves reversal of the operative sequence with lymphovascular and rectal dissection to precede proximal colonic mobilization. This technique evolved from a conventional-hybrid resection with laparoscopic vascular control, colonic mobilization, and robotic pelvic dissection. Perioperative and short-term oncologic outcomes were analyzed.

RESULTS: : Thirty patients underwent reverse-hybrid resection. Median tumor location was 5 cm (interquartile range 3-9) from the anal verge. Median BMI was 27.6 (interquartile range 25.0-32.1 kg/m). Twenty (66.7%) received neoadjuvant chemoradiation. There were no conversions. Median blood loss was 100 mL (interquartile range 75-200). Total operation time was a median 369 (interquartile range 306-410) minutes. Median docking time was 6 (interquartile range 5-8) minutes, and console time was 98 (interquartile range 88-140) minutes. Resection was R0 in all patients; no patients had an incomplete mesorectal resection. Six patients (20%) underwent extended lymph node dissection or en bloc resection.

CONCLUSIONS: : Reverse-hybrid robotic surgery for rectal cancer maximizes the therapeutic applicability of the robotic and conventional laparoscopic techniques for optimized application in minimally invasive rectal surgery.

PMID: 22228169 [PubMed - in process]

Self-assessment quiz: answers, critiques, and references.

Dis Colon Rectum. 2012 Feb;55(2):e19-20

Authors:

PMID: 22228170 [PubMed - in process]

Residency programs in colon and rectal surgery.

Dis Colon Rectum. 2012 Feb;55(2):e28-30

Authors:

PMID: 22228171 [PubMed - in process]

To operate or not to operate? Should functional outcomes after sigmoid colectomy for diverticulitis influence our decision making?

Dis Colon Rectum. 2012 Jan;55(1):1-3

Authors: Friel CM

PMID: 22156860 [PubMed - in process]

Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision?

Dis Colon Rectum. 2012 Jan;55(1):4-9

Authors: Kiran RP, Kirat HT, Rottoli M, Xhaja X, Remzi FH, Fazio VW

Abstract

BACKGROUND: : The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized.

OBJECTIVE: : This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure.

DESIGN: : This study is a retrospective review of prospectively gathered data.

SETTINGS: : This investigation was conducted at a tertiary center.

PATIENTS: : Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires.

RESULTS: : One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer.

LIMITATIONS: : This study was limited by its retrospective nature.

CONCLUSIONS: : Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.

PMID: 22156861 [PubMed - in process]

Sigmoidectomy syndrome? Patients’ perspectives on the functional outcomes following surgery for diverticulitis.

Dis Colon Rectum. 2012 Jan;55(1):10-7

Authors: Levack MM, Savitt LR, Berger DL, Shellito PC, Hodin RA, Rattner DW, Goldberg SM, Bordeianou L

Abstract

BACKGROUND: : Bowel function following surgery for diverticulitis has not previously been systematically described.

OBJECTIVE: : This study aimed to document the frequency, severity, and predictors of suboptimal bowel function in patients who have undergone sigmoid colectomy for diverticulitis.

DESIGN: : This study is a retrospective analysis.

SETTING: : This study was conducted at a large, academic medical center.

PATIENTS: : Three hundred twenty-five patients who underwent laparoscopic or open sigmoid colectomy with restoration of intestinal continuity for diverticulitis were included in the study population. Of these, 249 patients (76.6%) returned a 70-question survey incorporating the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, and the Memorial Bowel Function Instrument.

MAIN OUTCOME MEASURES: : Survey responders and nonresponders were compared with the use of χ and t tests. Responders with suboptimal bowel function (fecal incontinence, urgency and/or incomplete emptying) were then compared with those with good outcomes by the use of logistic regression analysis to determine the predictors of poor function.

RESULTS: : Of the responders, 24.8% reported clinically relevant fecal incontinence (Fecal Incontinence Severity Index ≥24), 19.6% reported fecal urgency (Memorial Bowel Function Instrument Urgency Subscale ≥4), and 20.8% reported incomplete emptying (Memorial Bowel Function Instrument Emptying Subscale ≥4). On logistic regression analysis, fecal incontinence was predicted by female sex (OR = 2.3, p = 0.008) and the presence of a preoperative abscess (OR = 1.4, p < 0.05). Fecal urgency was associated with female sex (OR = 1.3, p < 0.05) and a diverting ileostomy (OR = 2.1, p < 0.001). Incomplete emptying was associated with female sex (OR = 1.4, p < 0.05) and postoperative sepsis (OR = 1.9, p < 0.05).

LIMITATIONS: : This study was limited by the fact that we did not use a nondiverticulitis control group and we had limited preoperative data on the history of bowel impairment symptoms.

CONCLUSION: : One-fifth of patients reported fecal urgency, fecal incontinence, or incomplete emptying after surgery for diverticulitis. Despite the limitations of our study, these results are concerning and should be investigated further prospectively.

PMID: 22156862 [PubMed - in process]

Fecal incontinence in men: coexistent constipation and impact of rectal hyposensitivity.

Dis Colon Rectum. 2012 Jan;55(1):18-25

Authors: Burgell RE, Bhan C, Lunniss PJ, Scott SM

Abstract

BACKGROUND: : The pathophysiology of fecal incontinence in men is poorly established.

OBJECTIVE: : The aim of this study was to assess the coexistence of constipation and determine the impact of rectal sensorimotor dysfunction in males with fecal incontinence.

SETTING: : This study was conducted at a tertiary referral center.

PATIENTS: : Included were adult male patients referred for the investigation of fecal incontinence over a 5-year period who underwent full anorectal physiology testing and completed a standardized symptom questionnaire.

INTERVENTION: : Standardized symptom questionnaires were fully completed, and anorectal physiologic test results (including evacuation proctography) were evaluated.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the frequency of symptoms of associated constipation, the association of blunted rectal sensation (rectal hyposensitivity) with symptoms, and other physiologic measures.

RESULTS: : One hundred sixty patients met the inclusion criteria, and 47% of these patients described concurrent constipation. Fifty-four patients (34%) had sphincter dysfunction on manometry, only 19 of whom had structural abnormalities on ultrasound. Overall, 28 patients (18%) had rectal sensory dysfunction, 26 (93%) of whom had rectal hyposensitivity. Patients with rectal hyposensitivity were more likely to subjectively report constipation (77%) in comparison with patients with normal rectal sensation (44%; p = 0.001), allied with decreased bowel frequency (19% vs 2%; p = 0.003) and a sense of difficulty evacuating stool (27% vs 8%; p = 0.008). Cleveland Clinic constipation scores were higher in patients with rectal hyposensitivity (median score, 13 (interquartile range: 8-17) vs normosensate, 9 (5-13); p = 0.004). On proctography, a higher proportion of patients with rectal hyposensitivity had protracted defecation (>180 s; 35% vs 10%; p = 0.024) and incomplete rectal evacuation (<55% of barium neostool expelled, 50% vs 20%; p = 0.02).

LIMITATIONS: : This study was limited by the retrospective analysis of prospectively collected data.

CONCLUSIONS: : Only one-third of incontinent men had sphincteric dysfunction. Other pathophysiologies must therefore be considered. Nearly half of patients reported concurrent constipation, and one-sixth had rectal hyposensitivity, which was associated with higher frequencies of both symptomatic and objective measures of rectal evacuatory dysfunction. In the majority of adult males, fecal incontinence may represent a secondary phenomenon.

PMID: 22156863 [PubMed - in process]

Medium-term outcome of sacral nerve modulation for constipation.

Dis Colon Rectum. 2012 Jan;55(1):26-31

Authors: Govaert B, Maeda Y, Alberga J, Buntzen S, Laurberg S, Baeten CG

Abstract

BACKGROUND: : Sacral nerve modulation has been reported as a minimally invasive and effective treatment for constipation refractory to conservative treatment.

OBJECTIVE: : This study aimed to evaluate the efficacy and sustainability of sacral nerve modulation for constipation in the medium term (up to 6 years) and to investigate potential predictors of treatment success.

DESIGN: : We performed a retrospective review of prospectively collected data.

SETTINGS: : The study was performed at 2 tertiary-care centers in Europe with expertise in pelvic floor disorders and sacral nerve modulation.

PATIENTS: : Patients were eligible if they had had symptoms of constipation persisting for at least 1 year, if conservative treatment (dietary modification, laxatives and biofeedback therapy) had failed, and if predefined excluded conditions were not present.

INTERVENTION: : The first phase of the treatment process was percutaneous nerve evaluation. If this was successful, patients underwent sacral nerve modulation therapy with an implanted device (tined-lead and implantable pulse generator).

MAIN OUTCOME MEASURE: : Follow-up was performed at 1, 3, 6, and 12 months, and yearly thereafter. Outcome was assessed with the Wexner constipation score.

RESULTS: : A total of 117 patients (13 men, 104 women) with a mean age of 45.6 (SD, 13.0) years underwent percutaneous nerve evaluation. Of these, 68 patients (58%) had successful percutaneous nerve evaluation and underwent implantation of a device. The mean Wexner score was 17.0 (SD, 3.8) at baseline and 10.2 (SD 5.3) after percutaneous nerve evaluation (p < .001); the improvement was maintained throughout the follow-up period, although the number of patients continuing with sacral nerve modulation at the latest follow-up (median, 37 months; range, 4-92) was only 61 (52% of all patients who underwent percutaneous nerve evaluation). The sole predictive factor of outcome of percutaneous nerve evaluation was age: younger patients were more likely than older patients to have a successful percutaneous nerve evaluation phase.

LIMITATIONS: : The study was limited by a lack of consistent outcome measures.

CONCLUSIONS: : Despite improvement in Wexner scores, at the latest follow-up sacral nerve modulation was only being used by slightly more than 50% of the patients who started the first phase of treatment. Further studies are needed to reassess the efficacy and sustainability of sacral nerve modulation.

PMID: 22156864 [PubMed - in process]

Combined Ischemic and Neuropathic Insult to the Anal Canal in an Animal Model of Obstetric-Related Trauma.

Dis Colon Rectum. 2012 Jan;55(1):32-41

Authors: Griffin KM, Oʼherlihy C, Oʼconnell PR, Jones JF

Abstract

BACKGROUND:: Childbirth, in particular, when it involves instrumental vaginal delivery, can result in direct trauma to the external anal sphincter muscle. In addition, a global injury to the pelvic floor, including neurovascular injury to the anal sphincter complex, may occur. OBJECTIVE:: The aims of this study were to determine whether sensory drive from the anal canal and oxygenation of the external anal sphincter were compromised during simulated labor in a validated animal model of obstetric trauma. DESIGN:: Fifteen female Wister rats were operated on. Group 1 (n = 5) underwent pelvic balloon compression for 1 hour to simulate increased pelvic pressure during childbirth. Somatosensory cortical potentials, evoked by electrically stimulating the anal canal, were tracked. In group 2 (sham), the balloons were not inflated. In group 3, tissue PO2 values of the external anal sphincter and femoral arterial blood flow were measured simultaneously during the period of balloon inflation. RESULTS:: The peak amplitude of cortical evoked potentials was reduced (from 11.8 ± 1.5 μV to 3.1 ± 1.1 μV) during pelvic compression (p = 0.002, ANOVA). During this period, arterial blood flow to the hindlimb and the external anal sphincter tissue PO2 decreased by 20% (p < 0.001) and 60% (p < 0.001). CONCLUSION:: Pelvic compression that mimics obstetric trauma is associated with diminished anocortical drive. This neural insult may be compounded by concomitant ischemia of the external anal sphincter.

PMID: 22156865 [PubMed - as supplied by publisher]

Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only?

Dis Colon Rectum. 2012 Jan;55(1):51-8

Authors: Reshef A, Lavery I, Kiran RP

Abstract

BACKGROUND: : Previous reports suggest that patients with rectal cancer undergoing abdominoperineal resection have worse oncologic outcomes in comparison with those undergoing restorative rectal resection.

OBJECTIVE: : This study aimed to assess factors influencing oncologic outcomes for patients undergoing surgery for rectal cancer.

DESIGN: : This study is a retrospective review of prospectively gathered data.

SETTING: : Data were gathered from a prospective cancer database.

PATIENTS: : Patients were included who underwent radical resection for mid and lower third rectal cancer (1991-2006).

MAIN OUTCOME MEASURES: : The primary outcomes measured were the impact of various factors on perioperative outcomes, local recurrence, and disease-free survival for patients undergoing abdominoperineal resection.

RESULTS: : Four hundred thirteen (29%) patients underwent abdominoperineal resection and 993 (71%) underwent restorative resection for rectal cancer. Patients with abdominoperineal resection were older (p < 0.0001), had a higher mean ASA score (p < 0.001), worse tumor differentiation (p < 0.001), and higher tumor stage (p = 0.0001). Although overall morbidity was lower in the abdominoperineal resection group (p = 0.001), the length of stay was greater (p < 0.001). After a similar period of follow-up (5.2 ± 3.9 vs 5.3 ± 3.4 y, p = 0.58), local recurrence (7% vs 3%, p = 0.02) was higher after abdominoperineal resection, but overall survival (56% vs 71%, p < 0.001) and disease-free survival (54% vs 70%, p < 0.001) were lower. On multivariate analysis, higher stage, poor tumor differentiation, involved margins, and older age were associated with worse survival, whereas higher stage, poor tumor differentiation, and abdominoperineal resection were associated with greater recurrence. These worse oncologic outcomes persisted even when the groups were stratified based on the location of the cancer in mid or distal rectum and for patients with a clear circumferential margin.

LIMITATION: : This study was limited by its retrospective nature.

CONCLUSION: : Technical factors alone are unlikely to be responsible for the worse outcomes after abdominoperineal resection in comparison with restorative resection. A combination of patient- and tumor-related factors that may have indicated the choice of the procedure also probably contribute to the worse outcomes. Because patients undergoing abdominoperineal resection represent a high risk for poor outcomes, management strategies need to consider all these factors during treatment.

PMID: 22156867 [PubMed - in process]

Accuracy of endorectal ultrasound for measurement of the closest predicted radial mesorectal margin for rectal cancer.

Dis Colon Rectum. 2012 Jan;55(1):59-64

Authors: Phang PT, Gollub MJ, Loh BD, Nash GM, Temple LK, Paty PB, Guillem JG, Weiser MR

Abstract

BACKGROUND: : At present, pelvic phased array-coil MR is used as the validated imaging modality for measurement of the closest predicted radial mesorectal margin for rectal cancer. Endorectal ultrasound is also used to assess the clinical stage of the cancer that will determine the recommendation for neoadjuvant chemoradiation, but it has not been used to assess the closest predicted radial margin.

OBJECTIVE: : We propose to assess endorectal ultrasound identification of mesorectal margins and the measurement of the closest predicted radial tumor-mesorectal margin.

PATIENTS AND METHODS: : Patients included were those having MRI and endorectal ultrasound for evaluation of primary rectal cancer in 2010 at a tertiary cancer referral colorectal clinic. Clinical data, MRI, and endorectal ultrasound images were assessed. Two independent retrospective measurements of mesorectal dimensions were correlated to evaluate the reproducibility of identifying mesorectal margins. MRI and endorectal ultrasound images were compared for independent measurements of mesorectal dimensions and of the closest predicted radial mesorectal margin. MRI and endorectal ultrasound determination of margin involvement were assessed for agreement.

RESULTS: : Fifty-two patients were studied with an average rectal cancer distance to the anal verge of 6.8 cm. Interobserver correlation coefficients of endorectal ultrasound mesorectal dimensions ranged from 0.47 to 0.53 (p < 0.01). MR and endorectal ultrasound measurements of the closest predicted radial mesorectal margin were correlated r =0.56 (p < 0.0001). MR and endorectal ultrasound determination of margin involvement agreed in 81% of cases.

CONCLUSION: : Endorectal ultrasound has substantial agreement with MR to measure the closest predicted radial tumor-mesorectal margin. Correlations between observers and modalities for identification of mesorectal dimensions are modest. Further assessment is indicated to confirm endorectal ultrasound mesorectal measurements in a larger sample and to understand the advantages and disadvantages relative to MR.

PMID: 22156868 [PubMed - in process]

Early versus late surgery in patients with intestinal behçet disease.

Dis Colon Rectum. 2012 Jan;55(1):65-71

Authors: Jung YS, Hong SP, Kim TI, Kim WH, Cheon JH

Abstract

BACKGROUND: : To date, no studies have been conducted to evaluate the potential benefits of early surgery in patients with intestinal Behçet disease.

OBJECTIVE: : We investigated the long-term clinical outcomes in patients with intestinal Behçet disease first diagnosed at surgery (“early surgery”) compared with those requiring surgical resection during the course of the disease (“late surgery”).

DESIGN: : This is a retrospective cohort study.

SETTINGS: : This study was conducted at a single tertiary academic medical center.

PATIENTS: : We reviewed the medical records of 272 consecutive patients with intestinal Behçet disease between March 1986 and August 2010.

MAIN OUTCOME MEASURES: : The cumulative probabilities of clinical recurrence and reoperation after operation were the main outcomes measures.

RESULTS: : Forty of 272 patients were first diagnosed with intestinal Behçet disease at surgery (early surgery); the remaining 232 were diagnosed clinically, with 62 undergoing surgery during their follow-up after clinical diagnosis (late surgery). The cumulative probabilities of postoperative clinical recurrence and reoperation were significantly lower in the early-surgery group than in the late-surgery group (p = 0.045 and p = 0.003). In multivariate analysis, early surgery was the only independent factor significantly associated with a reduced probability of reoperation (HR 0.26; 95% CI 0.10-0.71; p = 0.008). However, when we analyzed only the patients who underwent surgery because of chronic symptoms, early surgery was not associated with lower cumulative clinical recurrence and reoperation rates (p = 0.896 and p = 0.492).

LIMITATIONS: : We analyzed the clinical characteristics retrospectively, and the number of patients was insufficient to reach a decisive conclusion.

CONCLUSIONS: : According to the current study, the patients with intestinal Behçet disease undergoing early surgery showed better prognoses in comparison with those undergoing late surgery. Early surgery may represent a valid approach in the initial management of the patients with intestinal Behçet disease, at least in the subset of the patients with acute symptoms.

PMID: 22156869 [PubMed - in process]

One-stage segmental colectomy and primary anastomosis after intraoperative colonic irrigation and total colonoscopy for patients with obstruction due to left-sided colorectal cancer.

Dis Colon Rectum. 2012 Jan;55(1):72-8

Authors: Sasaki K, Kazama S, Sunami E, Tsuno NH, Nozawa H, Nagawa H, Kitayama J

Abstract

BACKGROUND: : Intraoperative colonic irrigation and intraoperative on-table colonoscopy may be useful for a more accurate diagnosis of colorectal cancer before colectomy in patients with obstructive left-sided colorectal cancer, but the clinical benefit of this technique has not been investigated in large-scale studies.

OBJECTIVE: : The aim of this study was to evaluate the usefulness of intraoperative colonic irrigation with a Y-shaped irrigation device and intraoperative colonoscopy in the management of obstructive colorectal cancer in patients undergoing elective surgery.

DESIGN AND SETTING: : This was a retrospective cohort study of patients undergoing surgical treatment at a single tertiary care institution in Japan.

PATIENTS AND INTERVENTION: : Among 715 consecutive patients with left-sided colorectal cancer, 101 patients (14.1%) with obstructing tumor received intraoperative colonic irrigation and intraoperative colonoscopy before colectomy and primary anastomosis, and 614 patients with nonobstructive colorectal cancer underwent preoperative colonoscopy with mechanical bowel preparation.

MAIN OUTCOME MEASURES: : Detection rates of proximal synchronous lesions, occurrence of postoperative complications, and changes in the surgical procedure prompted by the results of the intraoperative colonoscopy were evaluated.

RESULTS: : Intraoperative colonoscopy detected synchronous adenomatous polyps in 27 patients (26.8%), carcinoma in 4 patients (4%), and obstructive colitis in 2 patients (2%). Findings of the intraoperative colonoscopy prompted changes in surgical procedure in 9 patients (8.9%). The overall morbidity in the intraoperative group was 17%, with anastomotic leakages in 3 patients, wound infection in 5, and postoperative ileus in 3 patients. The risk of these complications was not increased in patients with intraoperative colonoscopy with intraoperative colonic irrigation compared with those receiving preoperative colonoscopy with mechanical bowel preparation. The operation time was 28 minutes longer in the intraoperative than in the preoperative group, but neither the time to start of oral intake nor the length of postoperative hospital stay was significantly different between the 2 groups.

LIMITATIONS: : The study is limited by its retrospective nature.

CONCLUSIONS: : In patients with obstructive colorectal cancer, intraoperative colonic irrigation with intraoperative colonoscopy is a useful strategy for detecting synchronous lesions located proximally to the obstructing tumor, without increasing patient morbidity.

PMID: 22156870 [PubMed - in process]

Inflammatory bowel disease complicated by primary sclerosing cholangitis and cirrhosis: is restorative proctocolectomy safe?

Dis Colon Rectum. 2012 Jan;55(1):79-84

Authors: Lian L, Menon KV, Shen B, Remzi F, Kiran RP

Abstract

BACKGROUND: : The pattern and severity of postoperative complications after colectomy and total proctocolectomy with ileoanal pouch for patients with IBD with liver cirrhosis from primary sclerosing cholangitis have not been well characterized.

OBJECTIVE: : This study aimed to evaluate the immediate and long-term outcomes for patients with cirrhosis from primary sclerosing cholangitis undergoing colectomy for IBD.

DESIGN: : This is a retrospective study.

SETTING: : This study was conducted at Cleveland Clinic, a tertiary medical center.

PATIENTS: : From 1989 to 2009, 23 patients (22 ulcerative colitis and 1 Crohn’s disease) who underwent colectomy were included.

RESULTS: : The mean duration of primary sclerosing cholangitis before surgery was 6.8 ± 4.9 years, and the mean duration of IBD was 18 ± 10.7 years. All patients had cirrhosis; the mean Model for Endstage Liver Disease score was 9.3 ± 1.6, and most patients were Child Pugh class A or early B. Eight patients were on the orthotopic liver transplantation list. Indications for colectomy were dysplasia (n = 13), failure or complications of medical therapy (n = 7), cancer (n = 2), and colonic perforation at colonoscopy (n = 1). Nineteen patients (82.6%) developed postoperative complications including bleeding (43.5%), ileus (17.4%), wound infection (8.7%), worsening liver function (34.8%), pelvic abscess (13%), and deep vein thrombosis (8.7%). Two patients, both after total proctocolectomy/IPAA, died of septic shock after pelvic abscess in the postoperative period. Two patients underwent transjugular intrahepatic portosystemic shunt procedure before total proctocolectomy/IPAA; none developed pelvic abscess or mortality. There were no differences in mortality or morbidity between patients who underwent an ileoanal pouch procedure or colectomy with ileostomy.

CONCLUSIONS: : Colectomy in patients with IBD complicated with cirrhotic primary sclerosing cholangitis is associated with a high early postoperative morbidity rate. Due consideration needs to be given to strategies to reduce pelvic sepsis, especially after ileoanal pouch, because this is associated with mortality.

PMID: 22156871 [PubMed - in process]

Assessment of the quality of patient-orientated internet information on surgery for diverticular disease.

Dis Colon Rectum. 2012 Jan;55(1):85-9

Authors: Yeung TM, Mortensen NJ

Abstract

BACKGROUND: : The Internet is a vast resource available for patients to obtain health information.

OBJECTIVE: : This study examines the quality of Web sites that provide information on diverticular disease, treatment options, and surgery.

DESIGN: : Two search engines (Google and Yahoo) and the search terms “surgery and diverticular disease” and “surgery and diverticulitis” were used. The first 50 sites of each search were assessed. Sites that fulfilled the inclusion criteria were evaluated for content and scored by using the DISCERN instrument, which evaluates the quality of health information on treatment choices.

RESULTS: : Two hundred sites were examined, of which 60 (30%) provided patient-orientated information. 50 sites (25%) were duplicated, 7 (3.5%) were links, 10 (5%) were advertisements, 14 (7%) were resources for clinicians, 9 (4.5%) were message forums, 27 (13.5%) were articles, and 15 (7.5%) were dead links. Of the 60 Web sites that provided patient information, only 10 (16.7%) had been updated within the past 2 years. Seventeen (28.3%) sites were affiliated with hospitals and clinics, but another 17 (28.3%) sites were associated with private companies with commercial interests. Although most Web sites contained information on symptoms, complications, investigations, and treatment options of diverticular disease, 20 (33.3%) did not describe any of the risks of surgery, and 45 (75%) did not provide information on the timescale of recovery postoperatively. Eighteen sites did not provide balanced information on treatment options; of these, 7 were biased toward medical treatment and 6 focused on laparoscopic surgery. Overall, only 22 (36.7%) were identified as being “good” or “excellent” with the use of the DISCERN criteria.

CONCLUSIONS: : The quality of patient information on surgery for diverticular disease is highly variable, and Web sites that are sponsored by private companies may be biased in discussing treatment options. There is potential for the Internet to provide valuable information, and clinicians should guide patients to access high-quality Web sites.

PMID: 22156872 [PubMed - in process]

Perineal hernia repair after abdominoperineal rectal excision.

Dis Colon Rectum. 2012 Jan;55(1):90-5

Authors: Martijnse IS, Holman F, Nieuwenhuijzen GA, Rutten HJ, Nienhuijs SW

Abstract

BACKGROUND: : A perineal hernia can severely disable everyday activities. Its repair is a surgical challenge, and guidance by the literature is limited. The series described so far are small or encompass a long period in which even nonmesh techniques were used.

OBJECTIVE: : The aim of this study was to review recent results of a perineal mesh-based repair.

PATIENTS: : Medical charts of patients with a symptomatic perineal hernia after abdominoperineal resection due to rectal cancer were reviewed.

MAIN OUTCOME MEASURES: : Data included patients’ characteristics, operative details, recurrence, and complications.

RESULTS: : In total, 29 patients underwent repair of a symptomatic perineal hernia after an abdominoperineal resection due to rectal cancer. The majority was male (66%), and the median age was 59 years (range, 41-83). All patients received neoadjuvant treatment.From 2003 until 2006, polytetrafluoroethylene or Vypro mesh and Prolene 2.0 sutures were used for perineal hernia repair. All 8 repairs failed; repeated repair using various methods was successful in 63%. After 2006, the surgical technique was changed into a high-tension repair with the use of a nonabsorbable mesh. This technique was successful for 20 of 21 patients (95%). Complications encountered in the entire group of 29 patients were urinary retention (n = 2), wound infection, seroma, and fistula (n = 1 each).

LIMITATIONS: : Even though this is the largest group described in the literature, the results are limited because of the small number of patients.

CONCLUSION: : Repair of perineal hernia remains challenging and only a few reports offer advice on how to manage this unusual problem. However, superior results have been shown with the new mesh-based technique through perineal approach with only 5% recurrence.

PMID: 22156873 [PubMed - in process]

Epigenetic regulation and colorectal cancer.

Dis Colon Rectum. 2012 Jan;55(1):96-104

Authors: Matsubara N

Abstract

Epigenetic silencing of genes is now recognized to be an important mechanism for inactivation of tumor suppressor genes in carcinogenesis. Because the role of genetic alterations in colorectal carcinogenesis has been well studied, colorectal cancer also offers an excellent model for elucidation of epigenetic mechanisms involved in carcinogenesis. DNA methylation and histone modification are involved in a complex network to maintain gene silencing and cause carcinogenesis. DNA methylation of cancer-related gene promoters generally begins early in the process of tumorigenesis, affecting various types of colorectal cancer to differing degrees. These advances in the understanding of the biology of tumorigenesis can be expected to provide distinct biomarkers that will aid future diagnosis, risk assessment, and treatment methods for patients with colorectal cancer.

PMID: 22156874 [PubMed - in process]

Should we care about the internal anal sphincter?

Dis Colon Rectum. 2012 Jan;55(1):105-8

Authors: Zbar AP, Khaikin M

Abstract

The internal anal sphincter is currently regarded as a significant contributor to continence function. Four physiological and morphological aspects of the internal anal sphincter are presented as part of the current evidence base for its preservation in anal surgery. 1) The incidence of continence disturbance following deliberate internal anal sphincterotomy is underestimated, although there is presently no prospective imaging or physiologic data supporting the selective use of sphincter-sparing surgical alternatives. 2) Given that the resting pressure is a measure of internal anal sphincter function, its physiologic representation (the rectoanal inhibitory reflex) shows inherent differences between incontinent and normal cohorts which suggest that internal anal sphincter properties act as a continence defense mechanism. 3) Anatomical differences in distal external anal sphincter overlap at the point of internal anal sphincter termination may preclude internal anal sphincter division in some patients where the distal anal canal will be unsupported following deliberate internal anal sphincterotomy. 4) internal anal sphincter-preservation techniques in fistula surgery may potentially safeguard postoperative function. Prospective, randomized trials using preoperative sphincter imaging and physiologic parameters of the rectoanal inhibitory reflex are required to shape surgical decision making in minor anorectal surgery in an effort to define whether alternatives to internal anal sphincter division lead to better functional outcomes.

PMID: 22156875 [PubMed - in process]

Full-thickness skin graft anoplasty: novel procedure.

Dis Colon Rectum. 2012 Jan;55(1):109-12

Authors: Szeto P, Ambe R, Tehrani A, Cagir B

Abstract

We describe a novel technique to treat anal stenosis by reconstructing the anal canal by the use of a full-thickness skin graft from the abdominal wall. This treatment was successfully applied in our institution and showed positive results.

PMID: 22156876 [PubMed - in process]

Residency programs in colon and rectal surgery.

Dis Colon Rectum. 2012 Jan;55(1):e14-6

Authors:

PMID: 22156877 [PubMed - in process]

Colon and rectal surgery regional society meetings.

Dis Colon Rectum. 2012 Jan;55(1):e17-8

Authors:

PMID: 22156878 [PubMed - in process]

The authors reply.

Dis Colon Rectum. 2012 Jan;55(1):e3

Authors: Kwak JM, Baek SJ, Kim SH

PMID: 22156880 [PubMed - in process]

The evolving diagnosis and treatment of uncomplicated diverticulitis (from the perspective of emergency physicians).

Dis Colon Rectum. 2012 Jan;55(1):e4

Authors: Lutwak N, Dill C

PMID: 22156881 [PubMed - in process]

The authors reply.

Dis Colon Rectum. 2012 Jan;55(1):e4

Authors: Hogan A, Winter D

PMID: 22156882 [PubMed - in process]

Self-assessment quiz: answers, critiques, and references.

Dis Colon Rectum. 2012 Jan;55(1):e5-6

Authors:

PMID: 22156883 [PubMed - in process]

Long-term outcome of colectomy and ileorectal anastomosis for Crohn’s colitis.

Dis Colon Rectum. 2011 Nov;54(11):1347-54

Authors: O’Riordan JM, O’Connor BI, Huang H, Victor JC, Gryfe R, MacRae HM, Cohen Z, McLeod RS

Abstract

BACKGROUND: Ileorectal anastomosis is an important surgical option for patients with Crohn’s colitis with relative rectal sparing.

OBJECTIVE: This study aimed to audit outcomes of ileorectal anastomosis for Crohn’s and factors associated with proctectomy and reoperation.

DESIGN: This retrospective study involved a chart review and contacting patients.

SETTINGS: Patients with Crohn’s colitis who had an ileorectal anastomosis were identified from the Mount Sinai Hospital Inflammatory Bowel Disease Database.

PATIENTS: Demographics, operative and perioperative outcomes, and reoperative data were collected.

MAIN OUTCOME MEASURES: Five- and 10-year Kaplan-Meier survival estimates and 95% confidence intervals were calculated for survival from proctectomy and Crohn’s-related revisional surgery. Cox proportional hazards models were used to model the hazards of proctectomy and Crohn’s-related revision on the clinical characteristics of patients.

RESULTS: Eighty-one patients had an ileorectal anastomosis for Crohn’s disease from 1982 to 2010. The most common indications for surgery were failed medical management (60/81, 74.1%) and a stricture causing obstruction (14/81, 17.3%). Seventy-seven percent (n = 62) had a 1-stage procedure, whereas 23% (n = 19) had a 2-stage procedure (colectomy followed by ileorectal anastomosis). The overall anastomotic leak rate was 7.4% (n = 6). Fifty-six patients had a functioning ileorectal anastomosis at the time of follow-up. At 5 and 10 years, 87% (95% CI: 75.5-93.3) and 72.2% (95% CI: 55.8-83.4) of individuals had a functioning ileorectal anastomosis. Eighteen patients required proctectomy for poor symptom control, whereas 11 patients required a small-bowel resection plus redo-ileorectal anastomosis. The mean time to proctectomy from the original ileorectal anastomosis was 88.3 months (SD = 62.1). Smoking was associated with both proctectomy (HR 3.93 (95% CI: 1.46-10.55)) and reoperative surgery (HR 2.12 (95% CI: 0.96-4.72)).

LIMITATIONS: : This study was retrospective.

CONCLUSIONS: Ileorectal anastomosis is an appropriate operation for selected patients with Crohn’s colitis with sparing of the rectum. However, patients must be counseled that the reoperation rate and/or proctectomy rate is approximately 30%.

PMID: 21979177 [PubMed - indexed for MEDLINE]

Single-incision versus multiport laparoscopic right and hand-assisted left colectomy: a case-matched comparison.

Dis Colon Rectum. 2011 Nov;54(11):1355-61

Authors: Lee SW, Milsom JW, Nash GM

Abstract

UNLABELLED: BACKGOUND: New technology for single-incision laparoscopic colectomy is now commercially available, yet advantages of this approach over multiport laparoscopic colectomy have not been demonstrated.

OBJECTIVE: This study aimed to compare the outcomes of patients who underwent single-incision vs multiport laparoscopic colectomies.

DESIGN: Consecutive patients who underwent single-incision laparoscopic colectomies were case matched to patients who underwent multiport laparoscopic colectomies by age, operation, surgeon, diagnosis, and body mass index. Data from a prospective database and the medical records of patients treated were reviewed.

SETTINGS: This study took place at 2 tertiary care hospitals.

PATIENTS: Forty-six consecutive patients with a body mass index of 24 underwent single-incision laparoscopic colectomies (24 right, 18 sigmoid, 4 low anterior resection).

MAIN OUTCOME MEASURES: Perioperative outcomes and cosmesis and body image scores at 90 days were compared.

RESULTS: The largest incision length was significantly shorter for the single-incision group. Two patients with single incisions were converted to hand-assisted laparoscopic surgery and 4 required placement of a 5-mm trocar. A significantly greater portion of the operation was performed by the attending surgeons in the single-incision group. For right colectomies, operative times were similar. For left colectomies, operative time (149 ± 30 vs 126 ± 21 min) was significantly longer for the single-incision group. Time to flatus and bowel movements were significantly shorter for the single-incision group, but length of stay was similar. Cosmetic score was higher for the single-incision group (P = .03).

CONCLUSIONS: Single incision is equivalent to multiport laparoscopic colectomy with regard to safety and efficacy with smaller incision size and higher cosmetic scores. Operative times were equivalent, although a greater portion of the operation was performed by the attending surgeons in the single-incision group. Further prospective studies are warranted to evaluate the advantages of single-incision laparoscopic colectomy.

PMID: 21979178 [PubMed - indexed for MEDLINE]

Early discharge and hospital readmission after colectomy for cancer.

Dis Colon Rectum. 2011 Nov;54(11):1362-7

Authors: Hendren S, Morris AM, Zhang W, Dimick J

Abstract

BACKGROUND: Early discharge after colectomy has been shown to be feasible in studies from specialty centers, but we hypothesized that benefits of early discharge might be offset by higher risk of readmission in the surgical community as a whole. Minimizing readmissions is a national health policy priority.

OBJECTIVE: This study aimed to determine whether hospitals discharging patients early had increased readmission rates.

DESIGN: Patients undergoing colectomy surgery for cancer were studied using national Medicare data (MEDPAR database). Multiple logistic regression was performed to determine whether hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) had increased readmission rates. Results were adjusted for patient comorbidity, emergency operation, laparoscopic surgery, demographic factors, and complications. A separate analysis at the patient level was conducted to determine risk factors for readmission.

SETTINGS: Early discharge rates at US acute care hospitals were investigated.

PATIENTS: Patients 65 and older undergoing colectomy surgery for cancer (2003-2008, n = 477,461) were included.

MAIN OUTCOME MEASURE: The main outcome measure was 30-day, all hospital readmission rates.

RESULTS: Hospitals with a pattern of early discharge (median length of stay ≤ 5 d) were not found to have a higher risk-adjusted readmission rate than hospitals with the usual median length of stay (16.3% vs 15.7%, P = .077). However, changing the cutoff for “early discharge” to ≤ 4 days revealed an increased risk for readmission among “very early discharge” hospitals (risk-adjusted readmission rate 21.3% vs 15.7%, P < .001). At the patient level, independent risk factors for readmission included older age, male sex, black race, lower socioeconomic status, urgent/emergent surgery, comorbidities, complications, open (vs laparoscopic) surgery, and longer length of stay for the index hospitalization.

LIMITATIONS: Limitations of this study included the limitations of the administrative data and elderly population.

CONCLUSIONS: Hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) do not have a higher risk-adjusted readmission rate than other hospitals. These results support the safety of early discharge programs in the Medicare population.

PMID: 21979179 [PubMed - indexed for MEDLINE]

The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years.

Dis Colon Rectum. 2011 Nov;54(11):1368-72

Authors: Tan KK, Tan IJ, Lim FS, Koh DC, Tsang CB

Abstract

BACKGROUND: Although the ligation of intersphincteric tract technique is a promising sphincter-preserving option in managing anal fistulas, failures are still seen.

OBJECTIVE: This study aimed to illustrate the patterns of failures and recurrences following the ligation of intersphincteric tract procedure for anal fistulas.

DESIGN: This study is a retrospective review.

SETTINGS: This study was conducted at the Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, from April 2006 to September 2010.

PATIENTS: Ninety-three patients were evaluated.

INTERVENTIONS: All patients underwent the ligation of intersphincteric tract procedure for anal fistulas.

MAIN OUTCOME MEASURES: Failure was defined as nonhealing of the surgical wound or fistula. Recurrence was defined as the reappearance of the fistula after initial healing.

RESULTS: After a median follow-up of 23 (range, 1-85) weeks, there were 7 failures and 6 recurrences. The median time to healing was 4 (range, 1-12) weeks. The freedom from failure or recurrence at 1 year following the ligation of intersphincteric tract procedure was 78% (95% CI: 66%-90%). All 7 failures had discharge at the intersphincteric wound. Four had an unhealed internal opening, and 3 had isolated failures at the intersphincteric wound. Endoanal ultrasonography revealed a less complicated anatomy that enabled successful treatment with either local application of silver nitrate (n = 3) or fistulotomy (n = 4). All 6 recurrences had a demonstrable tract from the previous internal opening to an external opening with healing of the intersphincteric wound. The median time to recurrence was 22 (range, 15-33) weeks from the ligation of the intersphincteric tract procedure. Fistulotomy, repeat ligation of intersphincteric tract, or anocutaneous advancement flap procedure was successfully performed subsequently.

CONCLUSION: In patients with early failures, the medialization of the external opening to the intersphincteric wound simplified subsequent management. All recurrences should be reevaluated and managed accordingly.

PMID: 21979180 [PubMed - indexed for MEDLINE]

Sustained improvement in the anal sphincter function following surgical plication of rabbit external anal sphincter muscle.

Dis Colon Rectum. 2011 Nov;54(11):1373-80

Authors: Rajasekaran MR, Jiang Y, Bhargava V, Ramamoorthy S, Lieber RL, Mittal RK

Abstract

BACKGROUND: We recently found that the anal canal function and external anal sphincter contraction can be enhanced by surgically adjusting the EAS muscle sarcomere length in rabbits. A 20% length plication of the external anal sphincter muscle results in significant increase in the anal canal pressure and EAS muscle stress without affecting its passive tension. The durability of the beneficial effect of external anal sphincter muscle plication on the anal canal function is not known.

OBJECTIVE: We studied the long-term effects of optimal length external anal sphincter plication on the anal canal pressure, external anal sphincter sarcomere length, and anal canal histology.

DESIGN: Female rabbits (n = 16) were anesthetized and either sham (n = 4) or external anal sphincter plication (n = 12) surgery was performed.

MAIN OUTCOME MEASURES: The effect of external anal sphincter plication on the anal canal pressure was determined every 2 weeks for 6 months in 6 animals. Anal canal was harvested for sarcomere length and histological assessment.

RESULTS: External anal sphincter plication resulted in 50% to 60% increase in the anal canal pressure, and 80% to 90% increase in external anal sphincter muscle stress (during maximum electrical stimulus). The effect of plication was durable for the entire study period of 24 weeks. Sarcomere length increased from 2.11 ± 0.08 μm to 2.59 ± 0.03 μm immediately after plication and was 2.35 ± 0.08 μm at the end of 6 months. Histology revealed no significant differences in the muscle (30% vs 29%) or connective tissue components (70% vs 71%) of the anal canal between control and chronically plicated animals.

CONCLUSIONS: Normal external anal sphincter muscle plication results in long-term enhancement of the anal canal function without any untoward effects on the tissue architecture in the rabbit. External anal sphincter muscle plication could be an important strategy to improve the anal canal function in patients with anal incontinence.

PMID: 21979181 [PubMed - indexed for MEDLINE]

Determining levels of fecal incontinence in the community: a New Zealand cross-sectional study.

Dis Colon Rectum. 2011 Nov;54(11):1381-7

Authors: Sharma A, Marshall RJ, Macmillan AK, Merrie AE, Reid P, Bissett IP

Abstract

BACKGROUND: Fecal incontinence is a socially stigmatized condition, and its prevalence in the community has been problematic to quantify because of difficulty with its definition.

OBJECTIVE: This study estimates the community prevalence of fecal incontinence in New Zealand by 3 scales of measurement: patient perceptions of a “problem with bowel control,” their symptoms, and their quality of life. DESIGN/MAIN OUTCOME MEASURES: A postal survey of 2000 people, aged >18, randomly selected from the national electoral roll, was performed. This used a validated, reliability-tested, anonymous questionnaire, the Comprehensive Fecal Incontinence Questionnaire, incorporating the identification of a “problem with bowel control,” the Fecal Incontinence Severity Index, and the Fecal Incontinence Quality of Life Scale.

RESULTS: The response rate was 68.7%. A total of 14.7% (95% CI: 12.6-16.7) of participants “felt they had a problem with bowel control” and 12.4% (95% CI: 10.5-14.5) had fecal incontinence when defined using the Fecal Incontinence Severity Index table as “leakage of liquid or solid stool ≥ 1/month.” In terms of quality of life, 26.8% of the population (95% CI: 24.2-29.4) noted some impairment on the Fecal Incontinence Quality of Life Scale. In total, 155 (13.2%) participants reported at least 2 of the 3 possible diagnostic measures, and this may provide a way to incorporate the 3 measures into a new definition of fecal incontinence.

LIMITATIONS: This study incorporated a new “generic” question enquiring about an individual’s perception of a bowel control problem and also introduced a “cutoff” value for Fecal Incontinence Quality of Life Scale to attempt to identify those with any impairment “due to accidental bowel leakage.”

CONCLUSIONS: This study helps to highlight some of the challenges involved with suitably identifying those who have fecal incontinence within the community. The prevalence rate of 13.2% represents a realistic measure of the burden of fecal incontinence in the general population, and further research in this area is recommended.

PMID: 21979182 [PubMed - indexed for MEDLINE]

Does intra-abdominal desmoid disease affect patients with an ileal pouch differently than those with an ileorectal anastomosis?

Dis Colon Rectum. 2011 Nov;54(11):1388-91

Authors: Burgess A, Xhaja X, Church J

Abstract

BACKGROUND: Nobody has analyzed the sequelae of desmoids according to the type of surgery that precipitated them.

OBJECTIVE: This study aims to determine whether the clinical effects of abdominal desmoids would be worse in patients with restorative proctocolectomy than in patients with ileorectal anastomosis.

DESIGN: This is a retrospective, database study.

PATIENTS: Included were patients with familial adenomatous polyposis who had undergone proctocolectomy with IPAA or colectomy and ileorectal anastomosis, and subsequently developed an intra-abdominal desmoid tumor.

MAIN OUTCOME MEASURES: The primary outcome measures were the clinical course of the desmoids; morbidity, and the requirement for stoma.

RESULTS: There were 86 patients: 49 had restorative proctocolectomy and 37 had ileorectal anastomosis. Patient demographics were similar. Average follow-up was 9.8 years (range, 2.7-23.8) and 16.3 years (range, 2.3 – 42.9). Treatment of the desmoids included surgery (64.4% vs 65.6%), medical therapy (69.4% vs 59.5%), chemotherapy (36.2% vs 30.0%), and radiotherapy (4.5% vs 10.0%), and was the same for each group. The overall complication rate of desmoids was similar, approaching 70%. The risk of individual complications was also similar (bleeding (2.0% vs 0.0%), fistula (10.2% vs 13.5%), bowel obstruction (32.7% vs 48.6%), pain (34.7% vs 21.6%), and death related to desmoid tumors (2.0% vs 10.8%)); 38.8% of the restorative proctocolectomy group and 51.4% the ileorectal group had surgery for desmoid tumor complications (P = .21), and 22.4% and 22.2% of patients ultimately had permanent stomas.

LIMITATIONS: This study was limited by the relatively small numbers of patients.

CONCLUSION: The morbidity associated with desmoid tumors has not been shown to differ, whether they arise after restorative proctocolectomy or ileorectal anastomosis.

PMID: 21979183 [PubMed - indexed for MEDLINE]

Increased risk of colorectal cancer and dysplasia in patients with Crohn’s colitis and primary sclerosing cholangitis.

Dis Colon Rectum. 2011 Nov;54(11):1392-7

Authors: Lindström L, Lapidus A, Ost A, Bergquist A

Abstract

BACKGROUND: Almost 10% of all patients with primary sclerosing cholangitis receive a diagnosis of Crohn’s disease. Clinical characteristics and the risk of colon cancer or dysplasia in Crohn’s disease and primary sclerosing cholangitis are less well examined than in ulcerative colitis.

OBJECTIVE: This study aimed to describe the clinical characteristics and risk of colorectal dysplasia and cancer in Crohn’s disease in patients with primary sclerosing cholangitis.

DESIGN: This is a cohort study of all patients diagnosed with primary sclerosing cholangitis and colorectal Crohn’s disease at Karolinska University Hospital, Huddinge, 1978 to 2006. Each patient was matched for age and the onset of Crohn’s disease to 2 controls with colorectal Crohn’s disease without liver disease.

SETTING: This study was conducted at a tertiary referral center.

PATIENTS: Twenty-eight patients (61% male) with primary sclerosing cholangitis and Crohn’s disease and 46 patients (50% male) with Crohn’s disease alone were studied. Clinical and endoscopic data were retrieved from medical records. Colonic biopsies from patients with primary sclerosing cholangitis were re-reviewed.

MAIN OUTCOME MEASURES: The primary outcome measured was the proportion of patients developing colorectal cancer.

RESULTS: Colorectal cancer or dysplasia developed in 9 patients with primary sclerosing cholangitis and in 3 controls. Patients with primary sclerosing cholangitis were more likely to develop colorectal dysplasia or cancer than controls (OR 6.78; 95% CI (1.65-27.9); P = .016). In patients with primary sclerosing cholangitis compared with controls, perianal fistulas occurred in 3% vs 33% (P = .003), bowel strictures occurred in 7% vs 30% (P = .03), and bowel surgery was performed in 18% vs 46% (P = .01). Histological granulomas were seen in 29% of the patients with primary sclerosing cholangitis compared with 43% in controls (P = not significant).

LIMITATIONS: This study was limited by its retrospective nature and the limited cohort.

CONCLUSIONS: Primary sclerosing cholangitis is a risk factor for the development of colorectal cancer and dysplasia in Crohn’s disease. Obstructing disease and perianal fistulas are rare in primary sclerosing cholangitis and less common than in colonic Crohn’s disease without liver disease.

PMID: 21979184 [PubMed - indexed for MEDLINE]

Dynamic anal endosonography and MRI defecography in diagnosis of pelvic floor disorders: comparison with conventional defecography.

Dis Colon Rectum. 2011 Nov;54(11):1398-404

Authors: Vitton V, Vignally P, Barthet M, Cohen V, Durieux O, Bouvier M, Grimaud JC

Abstract

BACKGROUND: Pelvic floor disorders are frequent, especially in women. Surgeons need more information on the accuracy of available diagnostic techniques to make therapeutic decisions.

OBJECTIVE: This study aimed to compare the accuracy of dynamic anorectal endosonography and dynamic MRI defecography with conventional defecography as the criterion standard in the diagnosis of pelvic floor disorders.

DESIGN: We used a prospective crossover design in which patients underwent each procedure in random order within the same month.

SETTING: Investigations were conducted at a regional referral center in Marseille, France.

PATIENTS: Women with dyschezia who were undergoing diagnostic evaluation were eligible.

INTERVENTION: Dynamic anorectal endosonography, dynamic MRI, and conventional defecography were performed in all patients by 3 blinded operators.

MAIN OUTCOME MEASURE: The accuracy of dynamic anorectal endosonography and dynamic MRI in the diagnosis of pelvic floor disorders was assessed by calculating sensitivity, specificity, positive and negative predictive values, correlation coefficients, concordance rates, and the Cohen κ statistic, with conventional defecography used as the criterion standard.

RESULTS: The study comprised 56 women with a mean age of 50.7 (SD, 12.5) years. No significant differences were observed between dynamic anorectal endosonography and dynamic MRI in the number of patients with rectocele (P = .49), perineal descent (P = .11 when dynamic anorectal endosonography measured descent of the puborectalis muscle; P = .27 for bladder descent), or enterocele (P = .78); no differences were found between these techniques in sensitivity, specificity, or positive and negative predictive values. Diagnostic concordance with conventional defecography as the standard did not differ significantly between dynamic MRI and dynamic anorectal endosonography: Concordance rates for dynamic anorectal endosonography were 75% for rectocele, 64% for perineal descent, and 91% for enterocele (no rectal intussusception was found with dynamic anorectal endosonography); concordance rates for dynamic MRI were 82% for rectocele, 57% for perineal descent, 93% for enterocele, and 55% for rectal intussusception. Significantly more internal anal sphincter defects were found with dynamic anorectal endosonography than with dynamic MRI defecography: 21 patients (37.5%) vs 12 patients (21.4%); P = .02. Patient tolerance was significantly better for dynamic anorectal endosonography than for dynamic MRI (P = .002) or conventional defecography (P = .005). Most patients said they would choose dynamic anorectal endosonography (72.1%) rather than dynamic MRI (25.6%) or conventional defecography (2.3%) if follow-up were necessary (P < .001).

CONCLUSION: Dynamic anorectal endosonography and dynamic MRI defecography show equivalent diagnostic performance in assessing pelvic floor disorders. However, because of its better tolerance and availability, dynamic anorectal endosonography may be preferable as the initial imaging procedure after clinical examination in the evaluation of pelvic floor disorders.

PMID: 21979185 [PubMed - indexed for MEDLINE]

Diathermy excisional hemorrhoidectomy: a prospective randomized study comparing pedicle ligation and pedicle coagulation.

Dis Colon Rectum. 2011 Nov;54(11):1405-11

Authors: Bessa SS

Abstract

BACKGROUND: In hemorrhoidectomy, pedicle coagulation has been claimed to be associated with less postoperative pain compared with pedicle ligation.

OBJECTIVE: This study was designed to compare the effects of pedicle ligation vs pedicle coagulation on postoperative pain in patients undergoing diathermy excisional hemorrhoidectomy.

DESIGN: The study was conducted as a single-blind prospective randomized clinical trial.

SETTING: Patients were treated at a single tertiary-level teaching hospital (Main University Hospital) in Alexandria, Egypt, from February 2009 to October 2010.

PATIENTS: Patients with symptomatic grade III or IV hemorrhoids were eligible.

INTERVENTION: Patients were randomly allocated to receive either pedicle coagulation or pedicle ligation during 3-quadrant diathermy excision hemorrhoidectomy.

MAIN OUTCOME MEASURES: Patients reported postoperative pain daily on a visual analog scale (0-10, with 10 corresponding to the most severe pain) during the first 10 postoperative days. On-demand parenteral analgesic requirements were recorded during the first 24 hours after surgery. Operative time, postoperative complications, and wound healing rates at 6 weeks postoperatively were also recorded.

LIMITATIONS: No a priori power calculation could be performed, so it was not possible to tell whether nonsignificant differences were real or a result of chance.

RESULTS: A total of 136 patients were randomly assigned, and 120 patients completed the study (60 in each group). The overall median pain score for the first 10 postoperative days was significantly lower in the pedicle coagulation group than in the pedicle ligation group (4.65 vs 6.56, P < .001), and daily median pain scores were significantly lower for pedicle coagulation than for pedicle ligation throughout the first 6 postoperative days (P < .001). Postoperative pain scores followed different courses in the 2 groups. In the coagulation group, pain levels were lowest during the first 3 postoperative days, increasing from day 4 and then falling after day 8. In the ligation group, pain levels were highest during the first 4 postoperative days, then gradually decreased. The median number of analgesic ampoules required during the first 24 hours was also significantly lower for pedicle coagulation than for ligation: 1 (range, 0-3) vs 3 (range, 1-3); P < .001). The median operative time was 15 (range, 14-20) minutes with coagulation and 14.5 (range, 12-18) minutes with ligation (P < .001). No significant differences were observed in the incidence of postoperative complications or wound healing rates at 6 weeks postoperatively. No anal stenoses or recurrences were observed.

CONCLUSIONS: Pedicle coagulation is safe and provides a superior alternative to pedicle ligation by decreasing postoperative pain in the first 6 postoperative days, as well as reducing parenteral analgesic requirements during the first 24 hours postoperatively.

PMID: 21979186 [PubMed - indexed for MEDLINE]

Long-term outcomes of human acellular dermal matrix plug in closure of complex anal fistulas with a single tract.

Dis Colon Rectum. 2011 Nov;54(11):1412-8

Authors: Han JG, Wang ZJ, Zhao BC, Zheng Y, Zhao B, Yi BQ, Yang XQ

Abstract

BACKGROUND: Bioprosthetic plugs represent a promising technique for the treatment of anal fistula simple because they allow simple and repeatable application, preservation of sphincter integrity, minimal patient discomfort, and subsequent surgical options if needed. However, success rates vary widely.

OBJECTIVE: The aim of this study was to assess long-term outcome in patients treated with an acellular dermal matrix plug for closure of complex single-tract anal fistulas.

DESIGN: This was a retrospective analysis of a prospective database.

SETTING: The study was conducted at a university hospital in Beijing, People’s Republic of China.

PATIENTS: The study population comprised 114 patients treated between January 2007 and May 2010 for complex high transsphincteric anal fistula with a single tract.

INTERVENTION: Fistulas were treated with an acellular dermal matrix plug derived from donated human skin.

MAIN OUTCOME MEASURES: The main outcome measures were fistula closure rate and postoperative incontinence (Wexner scores).

RESULTS: No mortality or major complications were observed. The overall success rate was 54.4% (62/114), with a median follow-up of 19.5 (range, 11-46) months. Of the 52 patients with plug failure, 11 (21%) had plug extrusion and 9 (17%) had sepsis. Most plug failures occurred within 30 days, with only 1 plug failure occurring 6 months after surgery. On multiple logistic regression analysis, smoking (P < .001), long distance between external opening (P < .001), and performance of the operation by a nonexpert surgeon (P = .018) were significantly associated with plug failure. Of 40 patients who underwent cutting seton placement after plug failure, 33 (82.5%) reported a successful outcome. However, the rate of incontinence 6 months after seton placement was 75% (30/40), whereas the rate in the overall study population 6 months after insertion of the ADM plug was 1.75% (2/114; P < .001).

LIMITATIONS: This study was limited by its retrospective nature.

CONCLUSIONS: Given the low morbidity and relative simplicity of the procedure, we suggest that an acellular dermal matrix plug is a reasonable option for closure of complex anal fistulas with a single tract.

PMID: 21979187 [PubMed - indexed for MEDLINE]

Evaluation of a new synthetic plug in the treatment of anal fistulas: results of a pilot study.

Dis Colon Rectum. 2011 Nov;54(11):1419-22

Authors: de la Portilla F, Rada R, Jiménez-Rodríguez R, Díaz-Pavón JM, Sánchez-Gil JM

Abstract

BACKGROUND: The treatment of anal fistulas using plugs is a very promising method because of its simplicity and ability to be carried out on an ambulatory basis. If unsuccessful, it does not compromise subsequent alternative surgical techniques and/or products. However, success rates are variable.

OBJECTIVE: This pilot study was designed to investigate the safety and effectiveness of a new synthetic plug in the treatment of transsphincteric anal fistulas.

DESIGN: This was a prospective observational study.

SETTING: Patients were treated at 2 colorectal surgery centers in Spain (Seville and Huelva).

INTERVENTIONS: Anal fistulas were treated with a fistula plug made of bioabsorbable polymers (67% polyglycolide, 33% trimethylene carbonate).

PATIENTS: Starting in January 2009, consecutive adult patients with transsphincteric anal fistulas were evaluated.

MAIN OUTCOME MEASURES: Outcome measures included rates of successful fistula closure, complications, and continence (Jorge-Wexner incontinence score), assessed postoperatively at 1 week and again at 1, 3, 6, and 12 months. Healing was determined by clinical examination by a surgeon blinded for the intervention.

RESULTS: A total of 19 patients (18 men, 1 woman) with transsphincteric anal fistulas were included in the study. The median age was 49 (range, 33-65) years. Of these patients, 12 presented with fistula relapse. The median time from onset of symptoms to surgery was 12 (range, 6-120) months. Three patients had previously placed setons. The follow-up duration was 12 months. Relapse occurred in 16 patients (with a perianal abscess in 1), and successful closure was observed in 3 patients (15.8%).

LIMITATIONS: The number of patients was small, and time was needed for the learning curve of the technique.

CONCLUSIONS: This study indicates that the new synthetic plug is safe, but the fistula closure rate was low. Randomized studies are needed to further determine the role of the bioabsorbable synthetic plug in the management of anal fistulas.

PMID: 21979188 [PubMed - indexed for MEDLINE]