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]

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 - in process]

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-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 OUTOME 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 - 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]

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 - 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]

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 - 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]

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 - 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]

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 - in process]

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]

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 - in process]

Transparent Cap-Assisted Colonoscopy Versus Standard Adult Colonoscopy: A Systematic Review and Meta-analysis.

Dis Colon Rectum. 2012 Feb;55(2):218-25

Authors: Westwood DA, Alexakis N, Connor SJ

Abstract

BACKGROUND: : Cap-assisted colonoscopy uses a transparent plastic hood attached to the tip of the colonoscope to flatten the semilunar folds and improve mucosal exposure. Several studies have examined the effect of cap-assisted colonoscopy on polyp detection, but the data are inconsistent.

OBJECTIVE: : This study aimed to evaluate whether cap-assisted colonoscopy improves the yield of colorectal neoplasia detected compared with standard colonoscopy.

DATA SOURCES: : A systematic search of the PubMed, MEDLINE, Embase, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction.

STUDY SELECTION: : Publications that compared cap-assisted colonoscopy vs standard colonoscopy in adults in a prospective randomized controlled study were selected for review.

MAIN OUTCOME MEASURES: : The primary outcomes used for meta-analysis were cecal intubation rate, cecal intubation time, and polyp detection rate. The analysis was performed using a fixed-effect model. Outcomes were calculated as odds ratios or standardized mean differences with 95% confidence intervals. The average polyp miss rate determined by tandem colonoscopy was also calculated.

RESULTS: : The outcomes of 6185 patients were studied. Cap-assisted colonoscopy detected significantly more patients with polyps (OR 1.13; p = 0.030) and had a lower average polyp miss rate (12.2% vs 28.6%) than standard colonoscopy. Cap-assisted colonoscopy had a significantly higher cecal intubation rate than standard colonoscopy (OR 1.36; p = 0.020), whereas the time to cecal intubation (standard mean difference, 0.04 min; p = 0.280) was similar for the 2 colonoscope types.

CONCLUSIONS: : Cap-assisted colonoscopy is associated with improved detection of colorectal neoplasia and higher cecal intubation rates than standard adult colonoscopy.

PMID: 22228167 [PubMed - in process]

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 - 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]

The association between anal function and neural degeneration after preoperative chemoradiotherapy followed by intersphincteric resection.

Dis Colon Rectum. 2011 Nov;54(11):1423-9

Authors: Nishizawa Y, Fujii S, Saito N, Ito M, Ochiai A, Sugito M, Kobayashi A, Nishizawa Y

Abstract

BACKGROUND: Preoperative chemoradiotherapy for rectal cancer is administered to improve local control, but it can also induce severe anal dysfunction after surgery.

OBJECTIVE: The goals of the study were to assess the influence of preoperative chemoradiotherapy on pathological findings and to examine the correlation of these findings with the cause of severe anal dysfunction after intersphincteric resection.

DESIGN: Peripheral nerve degeneration was evaluated histopathologically with the use of hematoxylin and eosin-stained sections of surgical specimens after intersphincteric resection, based on karyopyknosis, vacuolar degeneration, acidophilic degeneration of cytoplasm, denucleation, and adventitial neuronal changes. Each item was scored to quantify the level of neural degeneration, and the relationship between degeneration and anal function was examined at 12 months after closure of the stoma. Anal function was assessed by questionnaire, and incontinence was evaluated based on the Wexner score.

SETTING: This study was conducted at the National Cancer Center Hospital East from 2001 to 2006.

PATIENTS: The subjects were 68 patients with lower rectal cancer who underwent intersphincteric resection with (n = 47) or without (n = 21) preoperative chemoradiotherapy.

MAIN OUTCOME MEASURES: The findings in the 2 groups were compared to clarify the association between the degree of histological degeneration and postoperative anal function.

RESULTS: Neural degeneration was significantly higher in the chemoradiotherapy group, and the neural degeneration and Wexner scores had a significant correlation (P = .003, r = 0.477).

CONCLUSION: Preoperative chemoradiotherapy induced marked neural degeneration around the rectal tumor. The significant correlation between the degeneration score and postoperative anal function suggests that this score may be a useful marker to predict the influence of preoperative chemoradiotherapy on anal function after surgery.

PMID: 21979189 [PubMed - indexed for MEDLINE]

Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery.

Dis Colon Rectum. 2011 Nov;54(11):1430-7

Authors: Sheer AJ, Heckman JE, Schneider EB, Wu AW, Segal JB, Feinberg R, Lidor AO

Abstract

BACKGROUND: Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain.

OBJECTIVE: This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups.

DESIGN: This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis.

SETTING: Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007.

PATIENTS: Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy.

MAIN OUTCOME MEASURE: The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications.

RESULTS: Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality.

LIMITATIONS: Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors.

CONCLUSIONS: Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.

PMID: 21979190 [PubMed - indexed for MEDLINE]

Reoperation after colorectal surgery is an independent predictor of the 1-year mortality rate.

Dis Colon Rectum. 2011 Nov;54(11):1438-42

Authors: van Westreenen HL, Ijpma FF, Wevers KP, Afzali H, Patijn GA

Abstract

BACKGROUND: Comparative evaluation of surgical quality among hospitals must improve outcome and efficiency, and reduce medical costs. Reoperation after colorectal surgery is a consequence of surgical complications and therefore considered a quality-of-care indicator. With respect to the mortality rate, the 1-year mortality may be a more meaningful figure than in-hospital mortality, because it also reflects the impact of surgical complications beyond discharge.

OBJECTIVE: The aim of our study was to evaluate the 1-year mortality after colorectal surgery and to identify predicting factors.

DESIGN: This study was a retrospective analysis from our colorectal surgery database.

PATIENTS: All patients who underwent elective colorectal surgery from 2005 to 2008 were included.

MAIN OUTCOME MEASURES: Both univariate and multivariate analysis were performed to identify predicting factors. The following variables were analyzed: age, operative risk according to the ASA class, Charlson-Age Comorbidity Index, indication for and type of resection, primary anastomosis, tumor staging, anastomotic leakage, and reoperation.

RESULTS: For 743 consecutive patients, the 1-year mortality rate was 6.9%. Patients were operated on mainly because of colorectal cancer (n = 537; 72%). The rate of reoperation and in-hospital mortality was 12.8% and 2.4%. Univariate survival analysis demonstrated that ASA class, age, Charlson-Age Comorbidity Index, reoperation, and stage of disease were independent predictors of 1-year mortality. Multivariate analysis showed that ASA class (P = .020; HR 1.69), age (P = .015; HR 2.08) and reoperation (P = .001; HR 2.72) are directly correlated with 1-year mortality.

LIMITATIONS: Both patients with benign diseases and colorectal cancer are included. Furthermore, no clear guidelines on whether to perform a reoperation were available.

CONCLUSION: One-year mortality after colorectal surgery is independently predicted by ASA class, age, and reoperation. Our results underline the value of the 1-year mortality rate and the reoperation rate as parameters for quality assessment in colorectal surgery.

PMID: 21979191 [PubMed - indexed for MEDLINE]

Postoperative issues of sacral nerve stimulation for fecal incontinence and constipation: a systematic literature review and treatment guideline.

Dis Colon Rectum. 2011 Nov;54(11):1443-60

Authors: Maeda Y, Matzel K, Lundby L, Buntzen S, Laurberg S

Abstract

BACKGROUND: There is a lack of knowledge on the incidence and management of suboptimal therapeutic effect and the complications associated with sacral nerve stimulation for fecal incontinence and constipation.

OBJECTIVE: This study aimed to review current literature on postoperative issues and to propose a treatment algorithm.

DATA SOURCE: PubMed, MEDLINE, and EMBASE were searched using the keywords “sacral nerve stimulation,” “sacral neuromodulation,” “fecal incontinence,” and “constipation” for English-language articles published from January 1980 to August 2010. A further search was conducted on a wider literature using the keywords “complication,” “adverse effect,” “treatment failure,” “equipment failure,” “infection,” “foreign-body migration,” “reoperation,” “pain,” and “algorithm.”

STUDY SELECTION: Four hundred sixty-one titles were identified, and after a title and abstract review, 135 were subjected to full article review; 89 were finally included in this review. Five articles were added by manual search and consensus.

RESULTS: Forty-eight studies were identified as cohort studies reporting on postoperative issues, including 1661 patients who underwent percutaneous nerve evaluation and 1600 patients who proceeded to sacral nerve stimulation therapy. Pooled data showed that the most common problem during percutaneous nerve evaluation was lead displacement (5.3%). The incidence of suboptimal outcome, pain, and infection after implantation was 12.1%, 13.0%, and 3.9%.

LIMITATIONS: There was significant underreporting of untoward events, because 60% of the studies did not report complications during percutaneous nerve evaluation, and suboptimal outcome after implantation was not disclosed in 44% of the studies.

CONCLUSIONS: The incidence of untoward events associated with sacral nerve stimulation appears to be low. However, there is a significant underreporting of the incidence. Using the information from the structured and systematic literature review, we formulated a clinically relevant guideline for reporting and managing postoperative issues. The guideline can provide a framework for clinical practice.

PMID: 21979192 [PubMed - indexed for MEDLINE]

Perineural invasion is a strong and independent predictor of lymph node involvement in colorectal cancer.

Dis Colon Rectum. 2011 Nov;54(11):e273

Authors: Betge J, Pollheimer MJ, Kornprat P, Rehak P, Vieth M, Langner C

PMID: 21979193 [PubMed - indexed for MEDLINE]

Operative approach and venous thromboembolism in colorectal surgery: casual or causal association?

Dis Colon Rectum. 2011 Dec;54(12):1463-4

Authors: Fleming FJ

PMID: 22067172 [PubMed - in process]

Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano.

Dis Colon Rectum. 2011 Dec;54(12):1465-74

Authors: Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD

PMID: 22067173 [PubMed - in process]

Readmission rates and cost following colorectal surgery.

Dis Colon Rectum. 2011 Dec;54(12):1475-9

Authors: Wick EC, Shore AD, Hirose K, Ibrahim AM, Gearhart SL, Efron J, Weiner JP, Makary MA

Abstract

BACKGROUND: : Hospital readmission is emerging as a quality indicator by the state, federal, and private payors with the goal of denying payment for select readmissions.

OBJECTIVE: : We designed a study to measure the rate, cost, and risk factors for hospital readmission after colorectal surgery.

STUDY DESIGN/SETTING: : We reviewed commercial health insurance records of 10,882 patients who underwent colorectal surgery over a 7-year period (2002-2008).

PATIENTS: : All patients undergoing colon and/or rectal resection ages 18 to 64 were included.

MAIN OUTCOME MEASURE: : The 30-day and 90-day readmission rates, the number of readmissions per patient, the median cost, length of stay, and risk factors for readmission were analyzed.

RESULTS: : Thirty-day readmission occurred in 11.4% (1239/10,882) of patients. Readmission between 31 and 90 days occurred in an additional 11.9% (1027/10,882) of patients for a total 90-day readmission rate of 23.3%. Two or more readmissions occurred in 1.4% (155) and 5.2% (570) of patients in the first 30 and 90 days. Mean readmission length of stay was 8 days, and the median cost per stay was $8885. Initial hospitalization risk factors for readmission were the diagnosis of a surgical site infection (OR 1.2), creation of a stoma (OR 1.2), discharge to nursing home (OR 1.2), index admission length of stay >7 days (OR 1.2), proctectomy (OR 1.1), and severity of illness score (severity of illness 3 = OR 1.1; severity of illness 4 = OR 1.3).

CONCLUSIONS: : Readmission after colorectal surgery occurs frequently and is associated with a cost of approximately $9000 per readmission. Nationwide these findings account for $300 million in readmission costs annually for colorectal surgery alone. Clinical and systems-based prevention strategies are needed to reduce readmission.

PMID: 22067174 [PubMed - in process]

Preoperative diagnosis of lynch syndrome with DNA mismatch repair immunohistochemistry on a diagnostic biopsy.

Dis Colon Rectum. 2011 Dec;54(12):1480-7

Authors: Warrier SK, Trainer AH, Lynch AC, Mitchell C, Hiscock R, Sawyer S, Boussioutas A, Heriot AG

Abstract

BACKGROUND: : DNA mismatch repair immunohistochemistry on tumor tissue is a simple, readily available, and cost-effective method of identifying patients with Lynch syndrome in the postoperative setting. The aim of the study was to assess whether the mismatch repair status of a colorectal cancer can be confirmed by mismatch repair immunohistochemistry on preoperative biopsy.

DESIGN: : Germline positive patients with Lynch syndrome were identified from a prospectively collected Familial Cancer Clinic database. Preoperative colorectal cancer biopsy specimens were obtained from the source pathology provider to generate a cohort of matched preoperative and postoperative specimens. The specimens were sectioned and stained for 4 mismatch repair proteins (MLH1, MSH2, MSH6, PMS2). An age-matched cohort to compare specimens was selected from Bethesda positive but mismatch repair immunohistochemistry negative patients. All slides were reviewed by a single blinded pathologist. The Wilson method was used to calculate a true underlying proportion of patients for whom the preoperative result matched the postoperative test result with a 95% confidence interval.

RESULTS: : Of 128 germline positive mutation carriers, 40 patients (mean age 41, SD 11.3) had colorectal resections. Thirty-three preoperative specimens were retrievable and were matched with biopsies from 33 controls. The germline mutations included in the study were 8 MLH1, 19 MSH2, 3 MSH6, and 2 PMS2. In patients where germline positive status was known, sensitivity was 100% (95% CI 89.2-100) and specificity was 100% (95% CI 89.2-100). Identical sensitivity and specificity were observed in 33 age-matched patients. The sensitivity of the endoscopic biopsy in predicting germline status was 94.9% (95% CI 80.4-98.3).

CONCLUSION: : The mismatch repair disease status of a colorectal cancer can be reliably confirmed by mismatch repair immunohistochemistry on a diagnostic colorectal cancer biopsy sample before definitive surgery. Ascertaining a diagnosis of Lynch syndrome before definitive surgery can influence surgical planning.

PMID: 22067175 [PubMed - in process]

The impact of obesity on outcomes following major surgery for Crohn’s disease: an american college of surgeons national surgical quality improvement program assessment.

Dis Colon Rectum. 2011 Dec;54(12):1488-95

Authors: Causey MW, Johnson EK, Miller S, Martin M, Maykel J, Steele SR

Abstract

BACKGROUND: : Whereas Crohn’s disease is traditionally thought to represent a wasting disease, little is currently known about the incidence and impact of obesity in this patient cohort.

OBJECTIVE: : This study aimed to evaluate the perioperative outcomes in patients with Crohn’s disease who were obese vs those who were not obese undergoing major abdominal surgery.

DESIGN: : This study is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2008). Risk-adjusted 30-day outcomes were assessed by the use of regression modeling accounting for patient characteristics, comorbidities, and surgical procedures.

PATIENTS: : Included were all patients with Crohn’s disease who were undergoing abdominal operations.

MAIN OUTCOME MEASURE: : The primary outcomes measured were short-term perioperative outcomes. Obesity was defined as a BMI of 30 or greater.

RESULTS: : We identified 2319 patients (mean age, 41.6 y; 55% female). Of these patients, 379 (16%) met obesity criteria, 2% were morbidly obese, and 0.3% were super obese. Rates of obesity significantly increased each year over the study period. Twenty-five percent of the surgeries were performed laparoscopically (obese 21% vs nonobese 26%). Six percent were emergent, with no difference in patients with obesity. Operative times were significantly longer among patients with obesity (177 min) compared with patients who were not obese (164 min). After adjusting for differences in comorbidities and steroid use, overall perioperative morbidity was significantly higher in the obese cohort (32% vs 22% nonobese; OR 1.9). In addition, the rates of postoperative complications increased directly with rising BMI. Irrespective of procedure type, the patients who were obese were significantly more likely to experience wound infections (OR 1.7), which increased even further in patients who were morbidly obese (BMI >40; OR 7.1). By specific operation, postoperative morbidity was increased in patients with obesity following colectomies with primary anastomosis for both open and laparoscopic approaches (OR 2.9 and OR 3.8). Cardiac, pulmonary, and renal complications as well as overall mortality did not differ significantly based on BMI.

LIMITATIONS: : This study was limited by being a retrospective review, and by using data limited to the American College of Surgeons National Surgical Quality Improvement Program database.

CONCLUSION: : Increasing BMI adversely affects perioperative morbidity in patients with Crohn’s disease.

PMID: 22067176 [PubMed - in process]

Risk of postoperative venous thromboembolism after laparoscopic and open colorectal surgery: an additional benefit of the minimally invasive approach?

Dis Colon Rectum. 2011 Dec;54(12):1496-502

Authors: Shapiro R, Vogel JD, Kiran RP

Abstract

BACKGROUND: : Venous thromboembolism constitutes a major cause of morbidity associated with surgical procedures. Colorectal surgical patients are at an elevated risk for postoperative venous thromboembolism. Whether the laparoscopic approach influences this risk is not well defined.

OBJECTIVE: : This study aimed to assess the risk of venous thromboembolism following major colorectal procedures. The influences of laparoscopic and open approaches on venous thromboembolism were compared while controlling for other potential confounders.

DESIGN: : Patients who underwent major colorectal procedures were identified. Association between patient, disease, operation-related factors, and venous thromboembolism within 30 days of surgery was determined by the use of a logistic regression analysis.

SETTINGS: : Patients were identified from the National Surgical Quality Improvement Program database (2005-2008).

PATIENTS: : According to the National Surgical Quality Improvement Program database, 31,109 patients underwent colorectal surgery (open, 71%; laparoscopic, 29%) for cancer (48.3%), IBD (10.1%), diverticular disease (24.2%), and other benign conditions (17.4%).

MAIN OUTCOME MEASURES: : The primary outcomes measured were deep venous thrombosis and pulmonary embolism.

RESULTS: : The venous thromboembolism rate was 2.4% (laparoscopic 1.2% vs open 2.9%, P < .001). Patients who developed venous thromboembolism were older (age 65.4 vs 61.5, P < .001), more often male (52.5% vs 47.5%, P = .023), with worse functional status (P < .001), and more comorbidities (P < .001). Venous thromboembolism was associated with sepsis (7.9% vs 1.8%, P < .001), steroid use (5.4% vs 2.2%, P < .001), surgical site infection (4.8% vs 2%, P < .001), and reoperation (7% vs 2.1%, P < .001). On multivariate analysis, open surgery, older age, steroid use, sepsis, surgical site infection, reoperation, prolonged ventilation, and low albumin were independently associated with a higher venous thromboembolism rate.

LIMITATIONS: : The details regarding determinants of the decision for laparoscopic surgery, conversion rates for laparoscopic procedures, and thrombosis prophylaxis regimens were not available.

CONCLUSIONS: : The laparoscopic approach is associated with a lower venous thromboembolism rate in comparison with open surgery, despite controlling for other variables. This additional benefit of the minimally invasive approach further supports its use, whenever feasible, for a variety of colorectal conditions.

PMID: 22067177 [PubMed - in process]

The anatomical and surgical consequences of right colectomy for cancer.

Dis Colon Rectum. 2011 Dec;54(12):1503-9

Authors: Spasojevic M, Stimec BV, Gronvold LB, Nesgaard JM, Edwin B, Ignjatovic D

Abstract

BACKGROUND: : Current practice when performing right colectomy for cancer is to divide the feeding vessels for the right colon on the right side of the superior mesenteric vein.

OBJECTIVE: : This study aims to show that arterial stumps can be visualized through an early postoperative CT and analyze their anatomical and surgical characteristics.

DESIGN: : This study presents a retrospective review of prospective data.

SETTINGS: : The study was conducted at the Department of Surgery, Vestfold Hospital, Tonsberg, Norway.

PATIENTS: : Patients with leakage after a right colectomy for cancer (2003-2011) were identified through a local prospective complication registry (FileMaker Pro 9.0v3 software).

INTERVENTIONS: : Both preoperative and postoperative CTs were retrieved, reanalyzed, and 3-dimensionally reconstructed (Osirix v.3.0.2./Mimics v.13.1.). Patients without postoperative CTs were excluded.

MAIN OUTCOME MEASURES: : The main outcomes measured were length, caliber of presumed and actual arterial stumps, and their position relative to the superior mesenteric vein.

RESULTS: : Eighteen patients, median age 69 (10 men) were included. All patients had postoperative CTs, and 15 patients had preoperative CTs. Median time from operation to postoperative CT was 5 days. The ileocolic artery was found in 14 (11 CT pairs) patients, and the right colic artery was found in 5 (4 pairs) patients. Actual stump lengths were 28.0 mm (SD 9.3) and 37.3 mm (SD 14.9). A significant statistical difference between presumed and actual ileocolic artery stump lengths was found (P = .002). Posterior crossing to the superior mesenteric vein was noticed in 8 of 14 ileocolic arteries and in 3 of 5 right colic arteries. There was no statistical difference in mean caliber for the preoperative and postoperative right colic artery (P = .505) and ileocolic artery (P = .474).

LIMITATIONS: : Difficulties when interpreting the postoperative images, due to intra-abdominal effusion, staples, edema, and altered syntopy of blood vessels, were overcome through comparison with preoperative CTs.

CONCLUSION: : An early postoperative CT can show arterial stumps after right colectomy for cancer. These stumps appear to be significantly longer than presumed; implying a significant improvement potential when specimen size is concerned.

PMID: 22067178 [PubMed - in process]

Intramural and mesorectal distal spread detected by whole-mount sections in the determination of optimal distal resection margin in patients undergoing surgery for rectosigmoid or rectal cancer without preoperative therapy.

Dis Colon Rectum. 2011 Dec;54(12):1510-20

Authors: Shimada Y, Takii Y, Maruyama S, Ohta T

Abstract

BACKGROUND: : The current Japanese general rules for clinical and pathologic studies on cancer of the colon, rectum, and anus state that a 3-cm distal resection margin is needed in resecting rectosigmoid cancer and rectal cancer with a distal edge above the peritoneal reflection, and 2 cm is needed for rectal cancer with a distal edge below the peritoneal reflection. The appropriateness of these rules has not been proved.

OBJECTIVE: : Our aim was to evaluate the appropriateness of the Japanese rules.

DESIGN AND SETTING: : We retrospectively analyzed surgical and pathology records of patients who underwent surgery at a tertiary care cancer center in Japan.

PATIENTS: : The study included 381 consecutive patients with stage I to IV rectosigmoid or rectal cancer without preoperative chemotherapy or radiotherapy.

MAIN OUTCOME MEASURES: : We investigated both intramural and mesorectal distal spread, using whole-mount sections to measure the maximum length of distal spread. Long distal spread was defined as distal spread longer than the distal resection margin stated in the Japanese general rules. Risk factors for both distal spread and long distal spread were evaluated.

RESULTS: : Of 381 patients, 325 (85.3%) had no distal spread and a total of 56 (14.7%) had distal spread. Distal spread was within the limits specified by the Japanese general rules in 48 of the 381 patients (12.6%) and beyond the Japanese limits (long distal spread) in 8 patients (2.1%). The prevalence of distal spread increased with TNM stage (stage I, 2.7%; stage II, 5.3%; stage III, 17.4%; stage IV, 46.2%). Long distal spread was not observed in stage I or II, was found in only 1.4% of patients with stage III disease and in 11.5% of patients with stage IV. The maximum extent of distal spread in patients with rectosigmoid cancer or rectal cancer with the distal edge above the peritoneal reflection was 38 mm; in patients with rectal cancer with the distal edge below the peritoneal reflection, 35 mm. Multivariable analyses showed that nodal involvement and distant metastasis were independent risk factors for distal spread; distant metastasis was the only independent risk factor for long distal spread.

CONCLUSIONS: : The Japanese general rules specifying the distal resection margin are appropriate for most patients who undergo surgery for rectosigmoid and rectal cancer without preoperative chemotherapy or radiotherapy. A further increase of 1 to 2 cm beyond the recommended distal resection margin may contribute to improved local control for patients with distant metastasis.

PMID: 22067179 [PubMed - in process]

Long-term Follow-up Features on Rectal MRI During a Wait-and-See Approach After a Clinical Complete Response in Patients With Rectal Cancer Treated With Chemoradiotherapy.

Dis Colon Rectum. 2011 Dec;54(12):1521-8

Authors: Lambregts DM, Maas M, Bakers FC, Cappendijk VC, Lammering G, Beets GL, Beets-Tan RG

Abstract

BACKGROUND: : The “wait-and-see” policy instead of standard surgery for patients with rectal cancer who undergo a complete tumor regression after chemoradiation treatment is highly controversial. It is not clear yet how patients should be monitored once they are managed nonoperatively and whether follow-up by MRI has any potential role.

OBJECTIVE: : This study aimed to describe the rectal wall MRI morphology during short-term and long-term follow-up in patients with a clinical complete tumor response undergoing a wait-and-see policy without surgical treatment.

DESIGN, SETTING, AND PATIENTS: : As part of an observational study in our center, a cohort of 19 carefully selected patients with a clinical complete response after chemoradiation was managed with a wait-and-see policy and followed regularly (every 3-6 mo) by clinical examination, endoscopy with biopsies, and a rectal MRI. The MR morphology of the tumor bed was studied on the consecutive MRI examinations.

MAIN OUTCOME MEASURES: : The primary outcome measured was the morphology of the tumor bed on the consecutive MRI examinations performed during short-term (≤6 mo) and long-term (>6 mo) follow-up.

RESULTS: : Patients with a complete tumor response after chemoradiation presented with either a normalized rectal wall (26%) or fibrosis (74%). In the latter group, 3 patterns of fibrosis were observed (full-thickness, minimal, or spicular fibrosis). The morphology patterns of a normalized rectal wall or fibrosis remained consistent during long-term follow-up in 18 of 19 patients. One patient developed a small, endoluminal recurrence, which was salvaged with transanal endoscopic microsurgery. In 26% of patients, an edematous wall thickening was observed in the first months after chemoradiation, which gradually decreased during long-term follow-up. Median follow-up was 22 months (range, 12-60).

LIMITATIONS: : This was a small observational study, and had no histological validation.

CONCLUSIONS: : Four MR patterns of a persistent complete response of rectal cancer after chemoradiation were identified. These MR features can serve as a reference for the follow-up in a wait-and-see policy.

PMID: 22067180 [PubMed - in process]

Advancement flap repair: a good option for complex anorectal fistulas.

Dis Colon Rectum. 2011 Dec;54(12):1537-41

Authors: Jarrar A, Church J

Abstract

BACKGROUND: : Rectal advancement flap is a popular option for treatment of complex anal fistula. Although early outcomes vary, concerns remain about postoperative continence, long-term healing, and its role in patients with Crohn’s disease and anovaginal fistulas.

PURPOSE: : This study aimed to report long-term outcomes in patients with complex fistula disease.

PATIENTS: : Patients who were undergoing rectal advancement flap for anal fistula were included in the study.

DESIGN: : Patients were contacted to determine the status of their fistula disease, their bowel function, and their degree of fecal incontinence.

MAIN OUTCOME MEASURES: : The main outcomes measured were healing rate and continence.

RESULTS: : There were 98 patients, 43 men and 55 women, mean age 53 ± 14 years. Fifty-eight had cryptoglandular fistulas, and 40 (41%) had IBD (33 had Crohn’s disease). Seventy-seven of 98 patients had perianal fistulas, and all 77 underwent seton drainage before advancement flap. Twenty-one women had anovaginal fistulas. Average postoperative length of stay was 3 ± 1 days. There were no mortalities. Follow-up was possible in 75 patients, a mean of 7 ± 3 years after surgery. Primary healing occurred in 54 (72%) patients. Twenty-one patients (28%) underwent further treatment, and 12 (57%) healed after a second advancement flap. Four more patients healed after more than 2 flaps or fistulotomy leading to an overall healing rate of 70 of 75 (93%). Patients with Crohn’s disease had lower healing rates than those with cryptoglandular fistulas (87% vs 98%). Thirty-two patients (43%) had normal fecal continence before flap, and 43 (57%) had normal fecal continence after flap.

CONCLUSION: : Advancement flap is a good option for patients with complex anal fistulas.

PMID: 22067182 [PubMed - in process]

Proximity to Disease and Perception of Utility: Physicians’ vs Patients’ Assessment of Treatment Options for Ulcerative Colitis.

Dis Colon Rectum. 2011 Dec;54(12):1529-36

Authors: Brown LK, Waljee AK, Higgins PD, Waljee JF, Morris AM

Abstract

BACKGROUND: : Physician values regarding the benefit of continued medical therapy vs colectomy for moderate ulcerative colitis have not been defined. If physicians perceive these states differently than patients, their therapeutic recommendations may not align with patient values.

OBJECTIVE: : This study aimed to compare physician and patient willingness to trade life years with moderately active ulcerative colitis vs undergoing colectomy.

DESIGN: : This survey of physicians’ and patients’ utility values used standardized scenarios for moderately active ulcerative colitis and colectomy.

SETTING: : The investigation was conducted at a tertiary academic medical center.

METHODS: : Gastroenterologists, colorectal surgeons, and patients with ulcerative colitis who were either living with moderate disease or were postcolectomy completed the survey.

MAIN OUTCOME MEASURES: : Utility values were measured by the use of the time trade-off method.

RESULTS: : We surveyed 17 physicians, 150 postcolectomy patients, and 69 patients with moderate ulcerative colitis. Utility values for ulcerative colitis and colectomy states were (0.87, 0.95), (0.86, 0.92), and (0.91, 0.91). On average, physicians and postcolectomy patients assessed the utility of life with ulcerative colitis more poorly than the postcolectomy state. Patients with moderately active ulcerative colitis who had not undergone colectomy viewed both health states equally.

LIMITATIONS: : This study was limited by the physician subject sample size.

CONCLUSIONS: : Patients living with moderate ulcerative colitis value the pre- and postcolectomy states differently than physicians and postcolectomy patients. Recognizing the differences between their own and patients’ values may help physicians to better counsel patients preoperatively. In addition, exposure to postcolectomy patients may help those with moderate disease who are weighing the comparative benefits of colectomy.

PMID: 22067181 [PubMed - in process]

Scarless single-incision laparoscopic loop ileostomy: a novel technique.

Dis Colon Rectum. 2011 Dec;54(12):1542-6

Authors: Zaghiyan KN, Murrell Z, Fleshner PR

Abstract

BACKGROUND: : Laparoscopic surgery has become a favorable alternative to conventional open surgery for the creation of intestinal stomas, and it offers many benefits including reduced postoperative pain, ileus, and hospital stay. Single-incision laparoscopic surgery has been described for many abdominal operations. It may offer better cosmetic outcomes and reduce incisional pain, adhesions, and recovery time.

OBJECTIVE: : In this study, we aimed to describe a novel technique of scarless single-incision laparoscopic loop ileostomy for fecal diversion and to report our experience with 8 patients who underwent this procedure within a 1-year period.

DESIGN: : This study was designed as a retrospective case series.

SETTINGS: : This investigation was conducted at a single-institution, tertiary referral center.

PATIENTS: : Eight consecutive patients undergoing scarless single-incision laparoscopic loop ileostomy between August 2009 and August 2010 were included.

INTERVENTION: : Scarless single-incision laparoscopic loop ileostomies were performed.

MAIN OUTCOME MEASURES: : Among the outcomes measured were operation time, intraoperative blood loss, recovery of intestinal function, length of hospital stay, and surgical complications.

RESULTS: : Seven patients underwent surgery for active Crohn’s disease refractory to medical therapy. One patient underwent surgery for radiation-induced rectovesical fistula. Median surgery time was 76 minutes, and median intraoperative blood loss was 10 mL. Median length of postoperative hospitalization was 7 days. Of the 8 patients included in our series, 2 patients (25%) required reoperation for stoma ischemia because of vascular congestion that we attribute to a tight fascial opening or extensive bowel manipulation. Other surgical complications included nonoperative readmission for ileus and partial small-bowel obstruction (n = 2), anal dilation to evacuate an obstructed distal colon (n = 1), and peristomal cellulitis (n = 1).

LIMITATIONS: : This study was limited by its small sample size and its retrospective nature.

CONCLUSION: : Scarless single-incision laparoscopic loop ileostomy is a feasible alternative to standard laparoscopy for fecal diversion. Surgeons attempting this technique should do so with caution, given the high stoma ischemia rate in our small case series.

PMID: 22067183 [PubMed - in process]

Peutz-jeghers syndrome: intriguing suggestion of gastrointestinal cancer prevention from surveillance.

Dis Colon Rectum. 2011 Dec;54(12):1547-51

Authors: Latchford AR, Neale K, Phillips RK, Clark SK

Abstract

BACKGROUND: : Peutz-Jeghers syndrome is characterized by GI polyps and mucocutaneous pigmentation and carries an increased risk of GI cancer. GI polyps may bleed or cause intussusception. Luminal GI surveillance is recommended, but there are few data detailing outcomes from GI surveillance in Peutz-Jeghers syndrome.

OBJECTIVE: : This study aimed to assess outcomes from GI surveillance in patients with Peutz-Jeghers syndrome.

DESIGN: : This study is a retrospective review, using hospital and registry notes and endoscopy and histology reports.

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

PATIENTS: : All patients with Peutz-Jeghers syndrome who were followed up at St Mark’s hospital were included.

MAIN OUTCOME MEASURES: : The primary outcomes measured were surveillance procedures performed, complications, and long-term outcomes.

RESULTS: : Sixty-three patients from 48 pedigrees were included; the median age when patients were first seen was 20 years (range, 3-59). Only baseline investigations were performed in 12 patients. The remaining patients were followed up for 683 patient years, a median of 10 years (range, 2-41). Seven hundred seventy-six procedures were performed to assess the GI tract. These led to 5 double-balloon enteroscopies, 1 push enteroscopy, and 71 surgical procedures. Of the surgical procedures, 20 were performed as a result of baseline investigations, 12 arose from investigations of symptoms, and 39 were due to surveillance of asymptomatic patients. No emergency surgical interventions were performed. No luminal GI cancers were diagnosed. Of the 2461 polypectomies performed, 6 polyps contained atypia or dysplasia. Six complications arose from endoscopy or surgical intervention, requiring 5 laparotomies to manage these complications.

CONCLUSION: : GI surveillance in Peutz-Jeghers syndrome is relatively safe and avoids the need for emergency surgery for small-bowel polyps. The lack of GI cancers may reflect that surveillance and polypectomy have prevented cancer from developing, although the detection of neoplasia or dysplasia is uncommon.

PMID: 22067184 [PubMed - in process]

Bupivacaine Extended-Release Liposome Injection for Prolonged Postsurgical Analgesia in Patients Undergoing Hemorrhoidectomy: A Multicenter, Randomized, Double-blind, Placebo-controlled Trial.

Dis Colon Rectum. 2011 Dec;54(12):1552-9

Authors: Gorfine SR, Onel E, Patou G, Krivokapic ZV

Abstract

BACKGROUND: : Bupivacaine extended-release liposome injection is a novel formulation of bupivacaine designed to achieve long-acting postoperative analgesia.

OBJECTIVE: : The aim of this study was to compare the magnitude and duration of postoperative analgesia from a single dose of bupivacaine extended-release injection with placebo administered intraoperatively in patients undergoing hemorrhoidectomy.

DESIGN: : This evaluation was a multicenter, randomized, double-blind, parallel-group, placebo-controlled phase 3 study.

SETTINGS: : Data were obtained from 13 centers in the Republic of Georgia, Poland, and Serbia.

PATIENTS: : Included in this study were patients aged 18 to 86 years undergoing excisional hemorrhoidectomy.

INTERVENTIONS: : All patients received either a single dose of bupivacaine extended-release 300 mg or placebo administered intraoperatively via wound infiltration.

MAIN OUTCOME MEASURE: : The cumulative pain score was assessed by measurement of the area under the curve of pain intensity through 72 hours after study drug administration.

RESULTS: : One hundred eighty-nine patients were randomly assigned and treated; 186 completed the study. Pain intensity scores were significantly lower in the bupivacaine extended-release group in comparison with the group receiving placebo (141.8 vs 202.5, P < .0001). More patients in the bupivacaine extended-release group remained opioid free from 12 hours (59%) to 72 hours (28%) after surgery compared with patients receiving placebo (14% and 10%; P < .0008 through 72 h). The mean total amount of opioids consumed through 72 hours was 22.3 mg and 29.1 mg in the bupivacaine extended-release and placebo groups (P ≤ .0006). The median time to first opioid use was 14.3 hours in the bupivacaine extended-release group vs 1.2 hours in the placebo group (P < .0001). A greater proportion of patients in the bupivacaine extended-release group were satisfied with their postsurgical analgesia (95% vs 73%, P = .0007) than in the placebo group.

CONCLUSIONS: : Bupivacaine extended-release demonstrated a statistically significant reduction in pain through 72 hours, decreased opioid requirements, delayed time to first opioid use, and improved patient satisfaction compared with placebo after hemorrhoidectomy.

PMID: 22067185 [PubMed - in process]

Prevalence and pathophysiology of functional constipation among women in catalonia, Spain.

Dis Colon Rectum. 2011 Dec;54(12):1560-9

Authors: Ribas Y, Saldaña E, Martí-Ragué J, Clavé P

Abstract

BACKGROUND: : Specific treatment of functional bowel disorders requires precise diagnosis. However, prevalence and subtypes of functional constipation among women are not completely understood.

OBJECTIVE: : Our aim was to assess the prevalence of functional constipation and investigate the subtypes of dyssynergic defecation and slow transit constipation among Spanish women.

DESIGN: : We performed a prospective epidemiological study in healthy young women and retrospective pathophysiological studies in 2 patient cohorts of women with functional constipation according to Rome II criteria.

SETTINGS: : Referral centers at Clínica Sagrada Familia, Barcelona, Spain, and Hospital de Mataró, Mataró, Spain.

PATIENTS: : The epidemiological study included 600 healthy young women, aged 37.1 (SD, 8.2) years. Patient cohort 1 comprised 172 women with functional constipation without symptoms of pelvic floor dysfunction, ranging in age from 18 to 45 years. Patient cohort 2 comprised 106 women with functional constipation and symptoms of dyssynergic defecation, ranging in age from 45 to 65 years.

MAIN OUTCOME MEASURES: : In healthy women, a questionnaire was used to determine rates of functional constipation, dyssynergic defecation, and slow transit constipation. In patients, results of anorectal manometry, EMG, and colonic transit studies were reviewed to assess subtypes of functional constipation; in addition, results of dynamic videoproctography were reviewed in cohort 2 to assess the role of structural pelvic floor disorders.

RESULTS: : The prevalence of functional constipation in healthy young women was 28.8%; symptoms of dyssynergic defecation were found in 8.2%, those of isolated slow transit in only 0.17%. In patient cohort 1, a total of 143 patients (83.1%) showed dyssynergic defecation: 117 patients (68.0%) had paradoxical external anal sphincter contraction and 26 (15.1%) had impaired internal anal sphincter relaxation). Slow transit constipation without dyssynergia was observed in 15 (8.7%). Up to 40.2% of patients with dyssynergia also had delayed colonic transit. In the cohort of 106 women with dyssynergic defecation, videoproctography showed impaired puborectal relaxation in 64 patients (60.4%), anterior rectocele in 65 (61.3%), and rectal prolapse in 13 (12.3%).

LIMITATIONS: : We could not estimate the prevalence and subtypes of irritable bowel syndrome in the epidemiological study.

CONCLUSIONS: : Functional constipation is extremely prevalent among young, healthy, Spanish women, dyssynergic defecation being the most prevalent subtype. Slow transit constipation without dyssynergic defecation is uncommon. Structural pelvic floor disorders are highly prevalent in middle-aged women with dyssynergic defecation.

PMID: 22067186 [PubMed - in process]

Different Bowel Preparation Schedule Leads to Different Diagnostic Yield of Proximal and Nonpolypoid Colorectal Neoplasm at Screening Colonoscopy in Average-Risk Population.

Dis Colon Rectum. 2011 Dec;54(12):1570-1577

Authors: Chiu HM, Lin JT, Lee YC, Liang JT, Shun CT, Wang HP, Wu MS

Abstract

BACKGROUND:: Accumulating evidence indicates that the timing of bowel preparation is crucial, but its impact on the diagnostic yield of proximal or nonpolypoid colorectal neoplasm remains unclear. OBJECTIVE:: This study aimed to investigate the impact of the timing of bowel preparation on the adenoma detection rate for nonpolypoid colorectal neoplasm at colonoscopy. DESIGN:: This study is a retrospective analysis of a screening colonoscopy cohort database. SETTING:: The investigation was conducted at a screening colonoscopy unit in an university hospital. PATIENTS:: A consecutive series of 3079 subjects who received primary screening colonoscopy with different timing of bowel preparation was analyzed. INTERVENTION:: Different timing of bowel preparation (same day vs prior day) was studied. MAIN OUTCOME MEASURES:: The main outcomes measured were patient demographics, timing of bowel preparation, colon-cleansing levels, diagnostic yields of colonoscopy, including adenoma, advanced adenoma, and nonpolypoid colorectal neoplasm. RESULTS:: There were a total of 1552 subjects in the morning group and 1527 in the evening group. More subjects had proximal adenoma (175, 11.3% vs 138, 9.0%, P = .04), advanced adenoma (68, 4.4% vs 46, 13.0%, P = .044), nonpolypoid colorectal neoplasm (98, 6.3% vs 67, 4.4%, P = .018), proximal nonpolypoid colorectal neoplasm (71, 4.6% vs 40, 2.6%, P = .004), and advanced nonpolypoid colorectal neoplasm (25, 1.6% vs 12, 0.8%, P = .036) detected by same-day preparation. On multivariate regression analysis, the adenoma detection rate was significantly higher in the same-day group regarding overall and proximal adenoma (OR 1.23, 95% CI: 1.00-1.50; OR 1.35, 95% CI: 1.05-1.74), advanced adenoma (OR 1.53, 95% CI: 1.04-2.28), overall, proximal, and advanced nonpolypoid colorectal neoplasm (OR 1.48, 95% CI: 1.06-2.08; OR 1.82, 95% CI: 1.20-2.75; OR 1.96, 95% CI: 1.12-3.37). The adenoma detection rate was also significantly different among endoscopists. LIMITATION:: This was a single-center, nonrandomized trial. CONCLUSIONS:: Improving bowel preparation quality by same-day preparation may lead to enhanced detection of overall, proximal, and advanced nonpolypoid colorectal neoplasm.

PMID: 22067187 [PubMed - as supplied by publisher]

Usefulness of an intensive bowel cleansing strategy for repeat colonoscopy after preparation failure.

Dis Colon Rectum. 2011 Dec;54(12):1578-84

Authors: Ibáñez M, Parra-Blanco A, Zaballa P, Jiménez A, Fernández-Velázquez R, Ortiz Fernández-Sordo J, González-Bernardo O, Rodrigo L

Abstract

BACKGROUND: : No consensus exists regarding the optimal bowel preparation regimen for patients with poor bowel cleansing at a previous colonoscopy.

OBJECTIVE: : We investigated the usefulness of an intensive cleansing regimen for repeat colonoscopy after previous failure of bowel preparation.

DESIGN AND SETTING: : A prospective observational study was performed in patients undergoing colonoscopy at a university-based, tertiary referral hospital.

PATIENTS AND INTERVENTION: : Outpatients with inadequate preparation at an index colonoscopy were offered a repeat colonoscopy and instructed to follow an intensive preparation regimen consisting of a low-fiber diet for 72 hours, liquid diet for 24 hours, bisacodyl (10 mg) in the evening of the day before the colonoscopy, and a split dose of polyethylene glycol (1.5 L in the evening before and 1.5 L in the morning on the day of the colonoscopy).

MAIN OUTCOME MEASURES: : The adequacy of bowel cleansing was assessed according to the Boston Bowel Preparation Scale (0 or 1 on any colon segment = inadequate bowel preparation). Procedural variables, detection rates for polyps and adenomas, compliance, and tolerability of the regimen were assessed. Satisfaction with the regimen was assessed with a 10-point visual analog scale.

RESULTS: : Of 83 patients with inadequate bowel preparation at colonoscopy, 51 underwent a second colonoscopy and were analyzed; 46 patients (90.2%) had adequate bowel cleansing at the second colonoscopy, with a mean (SD) total Boston Bowel Preparation Scale score of 7.43 (1.5) and scores of 2.31 (0.6) for the right colon, 2.49 (0.6) for the transverse colon, and 2.63 (0.6) for the left colon. Polyps, flat lesions, or flat lesions proximal to the splenic flexure were found in significantly more patients at the second colonoscopy than at the index colonoscopy. The global satisfaction score was 6.6 (2.7).

LIMITATIONS: : The study was limited because of its open observational design, possible patient learning effect for bowel preparation at the repeat colonoscopy, and the inclusion of only outpatients.

CONCLUSIONS: : An intensive regimen consisting of a low-fiber diet, bisacodyl, and a split dose of polyethylene glycol can achieve good colon preparation with an improved detection rate for polyps and adenomas in most patients who have had poor bowel cleansing at a previous colonoscopy.

PMID: 22067188 [PubMed - in process]

Single-port laparoscopic diverting sigmoid colostomy.

Dis Colon Rectum. 2011 Dec;54(12):1585-8

Authors: Nguyen HM, Causey MW, Steele SR, Maykel JA

Abstract

BACKGROUND: : Single-port laparoscopic surgery has been described for various colorectal conditions. Here, we report the first 4 single-port laparoscopic sigmoid colostomies for fecal diversion.

METHODS: : A 1.5-cm-round incision was made on the skin at a previously marked colostomy site. A wound retractor was inserted and an access platform with four 5-mm trocars was attached to the wound retractor. The sigmoid colon was mobilized using electrocautery, laparoscopic scissors, or an advanced bipolar device. A standard Brooke colostomy was created through the initial skin incision.

RESULTS: : Four elective single-port laparoscopic diverting colostomies were performed. Indications included obstructing colon and rectal cancers and intractable Crohn’s proctitis. The average operative time was 73 minutes (range, 53-105), and blood loss was minimal (<50 mL). There were no intraoperative complications. Three of 4 patients received oral analgesia, and one patient received patient-controlled intravenous analgesia postoperatively. The average time to passage of flatus was 1 day. Diet was advanced either on the day of surgery or on postoperative day 1. The length of hospital stay ranged from 0 to 15 days.

CONCLUSION: : Single-port laparoscopic sigmoid colostomy is an effective technique that allows full intra-abdominal visualization and colonic mobilization while eliminating the need for additional skin incisions other than the colostomy site itself.

PMID: 22067189 [PubMed - in process]

The Long-term Gastrointestinal Functional Outcomes Following Curative Anterior Resection in Adults With Rectal Cancer: A Systematic Review and Meta-analysis.

Dis Colon Rectum. 2011 Dec;54(12):1589-1597

Authors: Scheer AS, Boushey RP, Liang S, Doucette S, Oʼconnor AM, Moher D

Abstract

BACKGROUND:: Significant variability and a lack of transparency exist in the reporting of anterior resection outcomes. OBJECTIVES:: This study aimed to qualitatively analyze the long-term functional outcomes and assessment tools used in evaluating patients with rectal cancer following anterior resection, to quantify the incidence of these outcomes, and to identify risk factors for long-term incontinence. DATA SOURCES:: MEDLINE, Embase, and CINAHL were searched using the terms rectal neoplasms, resection, and gastrointestinal function. STUDY SELECTION:: The studies included were in English and evaluated adults with rectal cancer, curative anterior resection, and a minimum 1-year follow-up. Patients with recurrent/metastatic disease were excluded. Of the 805 records identified, 48 articles were included. INTERVENTION:: The intervention performed was anterior resection. MAIN OUTCOME MEASURES:: The main outcome measure was incontinence (gas, liquid stool, and solid stool). RESULTS:: The histories of 3349 patients from 17 countries were summarized. Surgeries were conducted between 1978 to 2004 with a median follow-up of 24 months (interquartile range, 12, 57). Sixty-five percent of studies did not use a validated assessment tool. Reported outcomes and incidence rates were variable. The reported proportion of patients with incontinence ranged from 3.2% to 79.3%, with a pooled incidence of 35.2% (95% CI 27.9, 43.3). Risk factors for incontinence, identified by meta-regression, were preoperative radiation 0.009 and, in particular, short-course radiation (P = .006), and study quality (randomized controlled trial P = .004, observational P = .006). LIMITATIONS:: The meta-analysis was limited by the significant heterogeneity of the primary data. CONCLUSIONS:: Functional outcomes are inconsistently assessed and reported and require common definitions, and the more regular use of validated assessment tools, as well. Preoperative radiation and, in particular, short-course radiation may be a strong risk factor for incontinence; however, further studies are needed.

PMID: 22067190 [PubMed - as supplied by publisher]

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

Dis Colon Rectum. 2011 Dec;54(12):e286-7

Authors:

PMID: 22067192 [PubMed - in process]

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons, and the American Society of Colorectal Surgeons: Evidence Based Reviews in Surgery – Colorectal Surgery.

Dis Colon Rectum. 2011 Dec;54(12):1598-1600

Authors: Morris AM, Gryfe R, Thorson AG, Stoffel EM,

PMID: 22067191 [PubMed - as supplied by publisher]

Reviewers for and contributors to diseases of the colon & rectum.

Dis Colon Rectum. 2011 Dec;54(12):e294-6

Authors:

PMID: 22067193 [PubMed - in process]

Residency programs in colon and rectal surgery.

Dis Colon Rectum. 2011 Dec;54(12):e298-300

Authors:

PMID: 22067194 [PubMed - in process]

Anal vector volumetry: a bridge too far.

Dis Colon Rectum. 2011 Oct;54(10):e258; author reply e258

Authors: Zbar AP

PMID: 21904128 [PubMed - indexed for MEDLINE]

Sessile serrated adenoma/polyp of the large intestine: a potentially aggressive lesion in need of a new screening strategy.

Dis Colon Rectum. 2011 Oct;54(10):1205-6

Authors: Snover DC

PMID: 21904132 [PubMed - indexed for MEDLINE]

Choosing your goals.

Dis Colon Rectum. 2011 Oct;54(10):1207-9

Authors: Beck DE

PMID: 21904133 [PubMed - indexed for MEDLINE]