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The article presents the author's predictions for the technological advances likely to occur over the next 10 and 50 years in the fields of colon and rectal surgery. He predicts that minimally invasive surgery will become the most common form of surgery within 10 years and that the role of the surgeon as part imaging specialist will be redefined. In 50 years, he sees the disappearance of surgery as it is known today, with painless and scarless procedures becoming commonplace.

Acute lower gastrointestinal hemorrhage is an uncommon and severe symptom. The overall mortality rate ranges from 5 to 12 percent and can approach 40 percent for persistent or recurring bleedings. We report a case of a patient with severe recurrent lower bleeding in whom, despite several repeated explorations and a blind subtotal colectomy, no lesion could be found. Multiple (n = 4) leveled stomas of the small bowel with succus entericus reinfusion were required to localize and treat the cause of the bleeding. This case report is followed by a review of the literature of the management of lower gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

The study investigated the impact of prior abdominal surgery on conversions and outcomes of laparoscopic right colectomy. A consecutive series of 414 patients with cancer or adenomas who underwent a laparoscopic right colectomy from March 1996 to November 2006 were studied for surgical conversions and outcomes. Conversion was defined as an incision length > 7 cm. Patients with prior abdominal surgery (n = 191) were compared with patients with no prior abdominal surgery (n = 223), and showed no significant differences in age, ASA classification, length of stay, operative time, blood loss, harvested nodes, tumor size, and specimen length. Significantly more wound infections occurred in the prior abdominal surgery group (22 vs.12, P = 0.023). Body mass index > 30 showed a three-fold increased risk of conversion. Fifteen percent of the no prior abdominal surgery patients and 17 percent of the prior abdominal surgery patients were converted ( P > 0.05). Conversion was associated with a longer mean length of stay (8.8 days) relative to laparoscopically completed cases (6.3 days) regardless of prior abdominal surgery history ( P < 0.0001). Laparoscopic right colectomy for neoplasia was not associated with a higher conversion rate or morbidity in patients with prior abdominal surgery. Prior abdominal surgery is not a contraindication to laparoscopic right colectomy. [ABSTRACT FROM AUTHOR]

Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. However, some limitation of traditional laparoscopic surgery may cause difficulties. Robotic-assisted surgery may overcome these pitfalls. From December 2005 to July 2007, 50 patients were selected for robotic-assisted colorectal resection mainly for cancer. Of the 50 patients enrolled, 32 (64 percent) were men and 18 (36 percent) were women. Their mean age was 66.7 (range, 37–92) years. The American Society of Anesthesiologists’ (ASA) class distribution was 13 (26 percent) ASA I, 24 (48 percent) ASA II, 12 (24 percent) ASA III, and 1 (2 percent) ASA IV. Forty-four patients suffered from cancer and six patients from benign disease. Amongst the cancer patients, 3 percent were at UICC (International Union Against Cancer) Stage 0, 36 percent at UICC Stage I, 24 percent at Stage II, 28 percent at Stage III, and 9 percent at Stage IV. The global conversion rate was 4 percent. The mean operative time was 338.8 minutes. It decreased as the experience increased (419 minutes in the first 20 cases vs. 346 minutes in the last 30 cases; P = 0.036). As a gross comparison, the results of a coeval standard laparoscopy group of patients were shown. Robotic laparoscopic colon surgery is feasible and safe. A longer operating time is needed. [ABSTRACT FROM AUTHOR]

The use of defunctioning ileostomy is a common practice to reduce the septic complications after anastomotic leakage in colorectal surgery. In open surgery, the fashioning of ileostomy is a straightforward procedure. However, in the laparoscopic approach, this can be a difficult task and obstructive complications can occur postoperatively. A retrospective review was undertaken for all patients who underwent laparoscopic colorectal resection and defunctioning loop ileostomy over a 15-year period. In this period, 161 patients underwent laparoscopic colorectal surgery with defunctioning ileostomy. Eight patients developed obstructive complications in the early postoperative period requiring surgical intervention (5 percent). All patients presented with intestinal obstruction from the fourth to the sixth postoperative day. The median time to reoperation was 9.5 days (range, 5 to 19). The causes of obstructive complications were twisting of the ileostomy (n = 3), adhesive kinking proximal to the ileostomy (n = 3), tight fascia (n = 1), and both tight fascia and twisting of ileostomy (n = 1). Six patients underwent laparotomy for diagnosis and refashioning of ileostomy. The seventh patient had endoscopic decompression of small bowel and refashioning of ileostomy. The last patient was successfully managed with combined endoscopic and laparoscopic approach. Various pitfalls can occur in laparoscopically created defunctioning ileostomy. Measures can be taken to minimize these technical errors. Various surgical reinterventions can be attempted to determine the cause. With combined uses of enteroscope and laparoscope, a laparotomy can be avoided. [ABSTRACT FROM AUTHOR]

Fast-track (enhanced recovery) care pathways for colonic surgery are becoming increasingly popular; however, there have been concerns regarding protocol compliance, high readmission rates, and also the true impact on morbidity rates with these protocols. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay, complications, and readmission rates. From December 2005 to March 2007, consecutive patients undergoing colonic surgery were prospectively studied. The comparison group consisted of a comorbidity-matched group of patients who had undergone similar surgery before establishment of the fast-track program. Fifty patients were included in each group. Groups were comparable at baseline. The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids, were fed earlier, mobilized earlier, passed flatus earlier, and were discharged earlier than the comparison group (4 vs. 6.5 days, P < 0.001). The numbers of patients with urinary infections (2 vs. 12, P = 0.008), ileus (5 vs. 18, P = 0.005), and cardiopulmonary complications (11 vs. 21, P = 0.032) were significantly lower in the fast-track group. There was no difference in the rate of readmission. Fast-track is a safe and effective approach for reducing hospital stay and morbidity following major colonic surgery. [ABSTRACT FROM AUTHOR]

Mosapride citrate (mosapride) is a serotonin 5-hydroxytryptamine 4 receptor agonist known to promote gastric emptying and large-intestine motility. We assessed the effect of mosapride on postoperative ileus following colon surgery. Forty patients with colon cancer undergoing hand-assisted laparoscopic colectomy were randomly assigned to a mosapride group or a control group. The mosapride group received 15 mg of mosapride by mouth with 50 ml of water three times a day, starting on postoperative day 1. The control group received 50 ml of water on the same schedule. Patients were allowed to resume oral feeding on the evening of postoperative day 2. Postoperative time to first bowel movement was evaluated by one investigator blinded to treatment. Postoperative gastric emptying was evaluated with the [13C]-acetate breath test at 24 and 48 hours after the operation. Postoperative time to first bowel movement was significantly shorter in the mosapride group than in the control group (48.5 vs. 69.3 hours, P = 0.0149). The time to maximal gastric emptying rate as determined by the breath test was significantly shorter in the mosapride group than in the control group at the 48-hour time point (27.9 vs. 35.3 minutes, P = 0.0294). Postoperative hospital stay was shorter in patients receiving mosapride than in controls (6.7 vs. 8.4 days, P = 0.0398). No adverse effects were observed with mosapride. Gastric emptying was improved by mosapride. The results suggested that the period of postoperative ileus following hand-assisted laparoscopic colectomy can be shortened by treatment with mosapride. [ABSTRACT FROM AUTHOR]

The risk of rectal cancer after colectomy and ileorectal anastomosis may be reduced in the last decades, as patients with severe polyposis now have an ileoanal pouch. We have reevaluated the risk of rectal cancer and proctectomy for all causes according to the year of operation. On the basis of the year of operation in 776 patients with ileorectal anastomosis and 471 pouch patients in Denmark, Finland, Holland, and Sweden, the “pouch period” was defined to start in 1990. Ileorectal anastomosis follow-up data was captured by May 31, 2006. The cumulative risk of rectal cancer and proctectomy was compared before and after 1990 by Kaplan-Meier analysis. In the prepouch period 56/576 patients (10 percent) developed rectal cancer, vs. 4/200 (2 percent) in the pouch period. Neither the cumulative risk of rectal cancer (p = 0.07) nor the cumulative risk of proctectomy (p = 0.17) changed. However, in females the cumulative risk of rectal cancer (p = 0.04) and of proctectomy (p = 0.03) were lower in the pouch period. Since the introduction of the ileoanal pouch rectal cancer has decreased after ileorectal anastomosis, but only statistically significant in females. This indicates that ileorectal anastomosis may still be justified in selected patients with mild adenomatosis, especially in young females. [ABSTRACT FROM AUTHOR]

This study was designed to evaluate the impact of a standardized laparoscopic intracorporeal right colectomy on the short-term outcome of patients with neoplasia. Consecutive patients with histologically proven right colon neoplasia underwent a standardized laparoscopic intracorporeal right colectomy with medial to lateral approach encompassing ten sequential steps: 1) ligation of ileocolic vessels, 2) identification of right ureter, 3) dissection along superior mesenteric vein, 4) division of omentum, 5) division of right branch of middle colic vessels, 6) transection of transverse colon, 7) mobilization of right colon, 8) transection of terminal ileum, 9) ileocolic anastomosis, 10) delivery of specimen. Values were medians (ranges). From July 2002 to June 2005, 111 laparoscopic intracorporeal right colectomies were attempted with a 5.4 percent conversion rate. There were 57 women and 54 men, aged 64.9 (range, 40–85) years, with body mass index of 33 (range, 20–43), American Society of Anesthesiology score of 2 (range, 2–4), 36.9 percent comorbidities, and 37.8 percent previous abdominal surgery. The indication for surgery was cancer in 109 patients. Operative time was 120 (range, 80–185) minutes. Estimated blood loss was 69 (range, 50–600) ml. Overall length of skin incisions was 66 (range, 60–66) mm; 29 (range, 2–41) lymph nodes were harvested. Length of stay was four (range, 2–30) days. Complication rate was 4.5 percent. A standardized laparoscopic intracorporeal right colectomy resulted in a favorable short-term outcome in unselected patients with neoplasia of the right colon. [ABSTRACT FROM AUTHOR]

The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery. From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality. Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis ( P < 0.05), postoperative complications ( P < 0.04), postoperative infections ( P < 0.01), and total colectomy procedures ( P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection ( P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites ( P < 0.04). Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk. [ABSTRACT FROM AUTHOR]

The goal of this study was to determine the rate of surgical site infection and compliance with process measures designed to prevent infection in a defined population of patients undergoing colorectal operations. A task-force consisting of surgeons, hospital infection control personnel, anesthesiologists, and nurses was convened to enforce the use of process measures to prevent infections. We monitored antibiotic selection, dosage, timing, redosing and discontinuation, hair removal technique, intraoperative and postoperative body temperature, and perioperative glucose control for 12 months by using electronic medical records. Patients underwent a minimum of 30 days of postoperative follow-up and the attending surgeon diagnosed infections. Between April 2006 and March 2007, 298 patients underwent abdominal colorectal operations. The overall infection rate was 20 percent for colon procedures and 11 percent for small-bowel procedures. Compliance for most process measures improved from the first to the fourth quarter, and during the final quarter, correct antibiotic dose and hair removal with clippers exceeded 90 percent. The rate of surgical site infection after colorectal surgery is likely to be higher than that reported in national quality improvement programs. Perfect compliance with performance measures may be difficult to attain. [ABSTRACT FROM AUTHOR]

This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery. Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups. There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 ± 58 vs. 208 ± 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 ± 31 vs. 184 ± 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group ( P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68). In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy. [ABSTRACT FROM AUTHOR]

This study was designed to evaluate the yield and cost of fever evaluations in average-risk inpatients after elective colorectal surgery. A 12-month, retrospective study was performed on patients who developed a postoperative fever ≥ 38°C after elective colorectal surgery. A positive fever evaluation was defined as a blood culture, urine culture, chest x-ray, or abdominal CT result that led to a change in patient management. Logistic regression, Fisher’s exact test, and chi-squared test were used; odds ratios were calculated. Of 133 patients, 26 percent had a positive evaluation. Blood culture, urine culture, chest x-ray, and CT were positive in 3, 8, 7, and 46 percent, respectively. Risk factors for a positive fever evaluation were temperature ≥ 38.5°C, fever evaluation after postoperative Day 6, and a clinical manifestation of systemic inflammatory response syndrome other than fever (all, P < 0.01). The cost per positive fever evaluation for the entire group, patients with 2 risk factors, or patients with 3 risk factors was $5,600, $4,200, and $2,140, respectively. The current approach to fever evaluation after elective colorectal surgery is low yield and costly. High fever, late postoperative fever, and systemic inflammatory response syndrome are risk factors for a positive fever evaluation after colorectal surgery. [ABSTRACT FROM AUTHOR]

Patients are frequently referred for resection of difficult colon polyps. Before colectomy the experienced surgeon has the option of repeating the colonoscopy to assess the polyp, tattoo the site, and potentially remove the polyp. The purpose of this study was to review our results with this approach. All new patients referred during a five-year period to an 11-physician colon and rectal surgical group with the diagnosis of colon polyp (CPT 211.3) that was not previously removed were retrospectively reviewed. Patients with rectal polyps, inflammatory bowel disease, previous cancer, or familial adenomatous polyposis were excluded. Patient demographics, details of the polyps, success of polypectomy, reasons for surgical resection, pathology, and complications were analyzed. The study population consisted of 252 patients with a mean age of 65 years. Eighty patients underwent resection upon referral without a repeat colonoscopy. Upon resection, invasive cancers were found in 13 cases. A total of 172 patients underwent at least one repeat colonoscopy by the colorectal surgeon. Of this group, 101 patients had successful polypectomy, thus avoiding major colectomy. The remaining 71 patients had a subsequent colon resection after at least one repeat colonoscopy. In 26 cases the polyp site was tattooed for later localization. There were nine postpolypectomy hemorrhages treated nonoperatively and two perforations. Repeat colonoscopy by an experienced surgeon leads to complete removal and avoidance of major colectomy in 58 percent of these cases. Patients with large difficult polyps referred for resection should be considered for repeat colonoscopy before surgery. [ABSTRACT FROM AUTHOR]

This study evaluated the long-term (5-year) durability of radiofrequency energy delivery for fecal incontinence. This was an extension of the follow-up from our original prospective study in which patients who suffered from fecal incontinence were treated with the SECCA® system for radiofrequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0–20), fecal incontinence-related quality of life score, and Medical Outcomes Study Short-Form 36 were administered to five years. Differences between baseline and follow-up were analyzed by using paired t-test. A total of 19 patients were treated and followed for five years, including 18 females (aged 57.1 (range, 44–77) years). The mean duration for fecal incontinence was 7.1 (range, 1–21) years. At five-year follow-up, the mean fecal incontinence score had improved from 14.37 to 8.26 ( P < 0.00025) with 16 patients (84.2 percent) demonstrating >50 percent improvement. All fecal incontinence-related quality of life scores improved, including lifestyle (2.43 to 3.15; P < 0.00075), coping (1.73 to 2.6; P < 0.00083), depression (2.24 to 3.15; P < 0.0002), and embarrassment (1.56 to 2.51; P < 0.0003). The social function component of the Short-Form 36 improved from 38.3 to 60 ( P < 0.05). There was a trend toward improvement in the mental component summary of the Short-Form 36 from 38.1 to 48.14. There were no long-term complications. Significant and sustained improvements in fecal incontinence symptoms and quality of life are seen at five years after treatment with the SECCA® system. This treatment should be considered for patients suffering from fecal incontinence not amenable to surgery and who have failed conservative management. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the impact of laparoscopic colorectal resection on short-term postoperative outcome in elderly patients. A series of 535 patients with colorectal disease who had been randomly assigned to laparoscopic (n = 268) or open (n = 267) resection was analyzed. A total of 201 patients (37.6 percent) were elderly (aged 70 years or older) and 334 patients (62.4 percent) were younger than aged 70 years. Follow-up for postoperative morbidity was performed for 30 days after hospital discharge. Elderly patients had a higher American Society of Anesthesiologists score compared with younger patients in both the laparoscopic and open groups ( P = 0.0001). In the open group, elderly patients had higher morbidity rate (37.5 vs. 23.9 percent; P = 0.02) and longer length of hospital stay (13 vs. 10.6; P = 0.007) compared with younger patients. In the laparoscopic group, morbidity rate (20.2 vs. 15.1 percent) and length of hospital stay (9.5 vs. 9.1) were similar in elderly and younger patients. In elderly patients, the laparoscopy-reduced morbidity rate (20.2 vs. 37.5 percent; P = 0.01) and length of hospital stay (9.5 vs. 13; P = 0.001) compared to the open approach. In younger patients, the advantages of the laparoscopic approach on morbidity rate (15.1 vs. 23.9 percent; P = 0.06) and length of stay (9.1 vs. 10.6; P = 0.004) were less pronounced. Laparoscopy improved short-term postoperative outcome more in elderly than in younger patients. Advanced age was associated with higher morbidity and longer length of stay only in patients who underwent open colorectal surgery. [ABSTRACT FROM AUTHOR]

Patients who have an emergency operation for colorectal cancer have poorer long-term survival outcomes compared with elective patients. This study was designed to define the role of tumor pathology as a basis for the differences in survival outcomes. There were 1,537 elective and 286 emergency patients who had an operation for bowel cancer from 1997 to 2003. Tumor pathology and survival data collected prospectively for these patients were compared by modes of presentation. Excluding 30-day mortality, emergency patients as a whole had a five-year all-cause survival rate of 39.2 percent compared with 64.7 percent for elective patients P < 0.0001 they also had more advanced Dukes C and D tumors ( P < 0.0001). The rates of early T1 and T2 cancers were 4.7 percent for the emergency and 25 percent for the elective group. Emergency cases had more lymph node-positive patients and N2 patients (57.1 vs. 41.8 percent and 26.6 vs. 15.9 percent, respectively; P < 0.0001). Curatively resected emergency colon patients again had more advanced Dukes staged tumors ( P < 0.0001) with a five-year survival rate of 51.6 percent compared with 75.6 percent for elective patients P < 0.0001. On stage-for-stage analysis, the survival rates for curatively resected Dukes B and C colon cancers remained worse for emergency patients ( P = 0.003 and P = 0.0002, respectively). Both emergency Dukes B and C groups had more T4 cases (21.5 vs. 10.6 percent; P = 0.017 and 26.4 vs. 15 percent; P = 0.016, respectively). Advanced tumor pathology is a basis for poor long-term survival in emergency colorectal cancers. [ABSTRACT FROM AUTHOR]

Children with familial adenomatous polyposis have a greater mortality and morbidity in the first decade of life compared with the general population. Some children with a more severe disease phenotype present early with colorectal adenomata and may require colectomy at an early age. We present our multidisciplinary clinic experience with familial adenomatous polyposis in children younger than age ten years at the time of presentation. A cross-sectional analysis was performed on all patients with suspected or confirmed familial adenomatous polyposis presenting in the first decade of life and followed by the multidisciplinary Pediatric Hereditary Polyposis Clinic at our institutions. Analysis included demographics, clinical presentation and course, gene mutation testing, endoscopic-histologic findings, and surgical outcome. Twenty-two children (11 males) presented with suspected or confirmed familial adenomatous polyposis. Two were discharged from follow-up after negative adenomatous polyposis coli gene mutation testing. The rest underwent annual hepatoblastoma surveillance through age ten years with negative findings. Twelve patients presented with symptoms: six had de novo familial adenomatous polyposis. Seven had gastrointestinal hemorrhage and went on to colonoscopy. Four patients with adenomatous polyposis coli gene mutation at codon 1309 were referred for colectomy before age ten years. Referral to colectomy was earlier in patients with 1309 mutation and with de novo familial adenomatous polyposis. Children with familial adenomatous polyposis younger than age ten years may present presymptomatically for disease surveillance. Familial adenomatous polyposis with adenomatous polyposis coli gene mutation at codon 1309 entails a risk of a more aggressive phenotype; early colectomy may be indicated in children harboring this gene mutation. [ABSTRACT FROM AUTHOR]

Adequate lymph node evaluation is important to stage colon cancers and make adjuvant treatment decisions. Studies have demonstrated improved survival when ≥ 12 nodes are examined. Our objective was to assess differences in the adequacy of nodal evaluation for right vs. left colon cancers. From the National Cancer Data Base (1998–2004), 142,009 N0M0 colon cancer patients were identified. Logistic regression was used to evaluate the number of nodes examined for right vs. left colectomies. Multivariable modeling was used to determine the impact of examining ≥ 12 nodes on survival. Of 142,009 patients, 79,444 (56 percent) had right colectomies, and 62,565 (44 percent) patients had left colectomies. More nodes were examined during right colectomies than left (median 12 vs. 8, P < 0.0001). When adjusted for patient, tumor, and hospital factors, patients undergoing left colectomy were less likely to have ≥ 12 nodes identified ( P < 0.0001). Patients were more likely to have ≥ 12 nodes identified for right and left colon cancers at high-volume hospitals. Survival was better with examination of ≥ 12 nodes for right and left colon cancers ( P < 0.0001). Evaluating ≥ 12 nodes for right and left colon cancers is a feasible, clinically relevant, and modifiable factor that will likely improve patient outcomes. [ABSTRACT FROM AUTHOR]

We reviewed the experiences of surgical intervention for neonatal and infantile-onset refractory colonic Crohn’s disease. All cases were male patients with medical therapy resistant colonic Crohn’s disease and anal lesions. Their quality of life was extremely poor because of long fasting, steroid complications, growth and mental retardation, and severe anal pain. Surgery, such as subtotal colectomy and/or ileostomy construction, induced remission and allowed these patients to wean off steroids administered generally. Pediatric Crohn’s Disease Activity Index scores of all patients were significantly decreased. Reversible steroid complications disappeared after operation. Anal ulcers and multiple perianal fistulas were improved and the patients never complained of anal pain. All patients were able to achieve catch-up growth. Parents of all patients are satisfied with a physical or social development of their child after operation. However, mental retardation and eating disorders still remained in two patients. Early induction of surgical therapy may present a better outcome and improve quality of life for medical therapy-resistant cases in neonatal and infantile severe colonic Crohn’s disease. [ABSTRACT FROM AUTHOR]

This study was designed to assess the impact of pelvic radiotherapy on the incidence of complications and colostomy-free survival of patients after a coloanal anastomosis for rectal cancer. A total of 192 patients underwent a coloanal anastomosis between 1982 and 2001: 87 patients did not receive pelvic radiotherapy; 105 patients received pelvic radiotherapy (39 preoperative and 66 postoperative). Early and late complications requiring surgical intervention and the colostomy-free survival rate were assessed by retrospective review of patient records. After a median follow-up of 62 months, 151 patients were alive. The most frequent complication was development of an anastomotic stricture (5-year rate of a stricture, 16 percent; 95 percent confidence interval, 10–21). Patients receiving pelvic radiotherapy had a higher rate of complications other than anastomotic strictures, including fecal incontinence, fistulas, abscesses, and bowel obstructions compared with patients not receiving pelvic radiotherapy (5-year rate: 20 percent (95 percent confidence interval, 10–29) vs. 5 percent (95 percent confidence interval, 0–10); P = 0.001). Patients receiving pelvic radiotherapy had a lower colostomy-free survival than did patients not receiving pelvic radiotherapy (5-year colostomy-free rate: 72 percent (95 percent confidence interval, 62–84) vs. 92 percent (95 percent confidence interval, 86–98); P < 0.001). There was no significant difference in the colostomy-free survival of patients receiving preoperative and postoperative pelvic radiotherapy. After coloanal anastomosis, a significant number of patients will have complications requiring surgical intervention, and some will require a permanent colostomy. Pelvic radiotherapy, whether it is administered preoperatively or postoperatively, significantly increases the need for a permanent colostomy. [ABSTRACT FROM AUTHOR]

Because of the relatively high morbidity and mortality of anastomotic leakage in patients with low rectal cancer who receive an anterior resection, many fecal diverting methods have been introduced. This study was designed to assess the efficacy and safety of the Valtrac™-secured intracolonic bypass in protecting low rectal anastomosis and to compare the efficacy and complications of Valtrac™-secured intracolonic bypass with those of loop ileostomy. From January 2002 to April 2006, 83 patients with rectal cancer who underwent elective low anterior resection received intracolonic bypass or ileostomy. Demographics, clinical features, and operative data were recorded. Forty-four patients (53 percent) received a Valtrac™-secured intracolonic bypass and 39 patients (47 percent) a loop ileostomy. The demographics and clinical features of the groups were similar. None of the patients developed clinical anastomotic leakage. Longer overall postoperative hospital stay (21.3 ± 5.8 days) and higher costs incurred (3.1 ± 0.9 × $1,000 U.S. dollars) were observed in the ileostomy group than in the intracolonic bypass group (12.5 ± 6.3 days, 4.4 ± 1.2 × $1,000 U.S. dollars; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (12.8 percent), bleeding (2.6 percent), and intestinal obstruction after stoma closure (5.1 percent). No complications were observed in the intracolonic bypass group except for the Valtrac™ ring discharging en bloc, which compromised fecal evacuation in two cases (4.5 percent). The Valtrac™-secured intracolonic bypass procedure is a safe, effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis. Valtrac™-secured intracolonic bypass, in contrast to loop ileostomy, avoids stoma-related complications or readmission for closure and is associated with decreased hospital time and cost. [ABSTRACT FROM AUTHOR]

A standard laparoscopic-assisted operation can be conducted with colorectal anastomosis performed after extraction of specimen and insertion of a pursestring via a small left iliac fossa or suprapubic incision, or completed via hand-assisted laparoscopic technique with a 7-cm to 8-cm suprapubic incision. This study compares the short-term outcomes of either technique. Sixty-three consecutive patients undergoing laparoscopic-assisted ultralow anterior resection or total mesorectal excision for rectal cancer were examined. The laparoscopic-assisted group (n = 31) had standard laparoscopic-assisted resection, whereas the hand-assisted laparoscopic group (n = 32) had a 7-cm to 8-cm suprapubic incision to allow an open colorectal anastomosis. In patients who were obese or have had multiple abdominal surgeries, the hand-assisted approach was generally favored. All patients had a diverting ileostomy. There was no conversion in either group. Mean operating time was significantly longer in the laparoscopic-assisted group (188.2 vs. 169.8 minutes; P < 0.0001). Mean duration for narcotic analgesia (1.65 vs. 3.38 days, P < 0.0001), mean time to flatus (1.97 vs. 3.19 days, P < 0.0001), and mean duration of intravenous hydration (2.45 vs. 3.88 days, P < 0.0001) were longer in the hand-assisted laparoscopic group. However, the mean length of hospital stay (5.8 vs. 5.9 days, P = 0.379) was similar. There was no major surgical complication in either group; chest infection, wound infection, and thrombophlebitis were similar between the laparoscopic-assisted group and the hand-assisted laparoscopic group. Adequacy of specimen harvest (distal tumor margins, P = 0.995; circumferential resection margin, P = 0.946; number of lymph nodes, P = 0.845) was similar. Although both laparoscopic-assisted and hand-assisted laparoscopic surgeries are safe and feasible for ultralow anterior resection, the hand-assisted technique significantly shortens operating time. [ABSTRACT FROM AUTHOR]

Local anesthetic wound infusion has been investigated in recent years as a potential alternative to standard analgesic regimens after major surgery. This study investigates the efficacy of a continuous wound infusion of ropivacaine in conjunction with best practice postoperative analgesia after midline laparotomy for abdominal colorectal surgery. We performed a randomized, participant and outcome assessor-blinded, placebo-controlled trial on patients presenting for major abdominal colorectal surgery at our institution between December 2003 and February 2006. Patients were allocated to receive ropivacaine 0.54 percent or normal saline via a dual catheter Painbuster Soaker™ (I-Flow Corporation, OH, USA) continuous infusion device into their midline laparotomy wound for 72 hours postoperatively. A total of 310 patients were included in this study. The continuous wound infusion of ropivacaine after abdominal colorectal surgery conveys minimal benefit compared with saline wound infusion. No statistically significant difference could be shown for: pain at rest, morphine usage, length of stay, mobility, nausea, or return of bowel function. There was a small, statistically significant difference in mean pain on movement on Day 1 for the ropivacaine group (adjusted mean difference −0.6 (range, −1.08 to −0.13)). Although this trend continued on Days 2 and 3, the differences between groups were no longer statistically significant. Management of pain after major abdominal colorectal surgery is best achieved through adopting a multimodal approach to analgesia. Delivery of ropivacaine to midline laparotomy wounds via a Painbuster Soaker™ device is safe, but we have not demonstrated any significant clinical advantage over current best practice. [ABSTRACT FROM AUTHOR]

In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy. General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery. From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993–1994 to 2004–2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures. Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is trending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery. [ABSTRACT FROM AUTHOR]

Worldwide, “centers of excellence” in rectal cancer surgery report high rates of anal sphincter-sparing surgery (70–90 percent) after proctectomy. The rate of sphincter-sparing surgery with reestablishment of intestinal continuity in the general population of the United Stares is unknown. We used data from the Nationwide Inpatient Sample, a 20 percent stratified random sample of patients admitted to hospitals in the United States. We identified patients with rectal cancer from 1988 through 2003 who underwent sphincter-sparing surgery with reestablishment of intestinal continuity or proctectomy with colostomy. To determine predictors of sphincter-sparing surgery with reestablishment of intestinal continuity, we constructed a multivariate model that analyzed patients’ age, gender, race, insurance status, and income level. During our 16-year study period, radical extirpative procedures were performed in 41,631 patients: 16,510 (39.7 percent) sphincter-sparing surgery with reestablishment of intestinal continuity, and 25,121 (60.3 percent) sphincter-sacrificing procedures. The proportion of sphincter-sparing procedures increased from 26.9 percent in 1988 to 48.3 percent in 2003 ( P < 0.001). There has been no significant change in the rate of sphincter-sparing surgery since 1999 ( P = not significant). Logistic regression revealed that patients who were older, male, black, used Medicaid insurance, or lived in lower-income zip codes were less likely to have sphincter-sparing surgery with reestablishment of intestinal continuity ( P < 0.001). Despite a significant increase in the rate of sphincter-sparing surgery with reestablishment of intestinal continuity, most radical resections for rectal cancer in hospitals in the United States result in a colostomy. Patients vulnerable to proctectomy without sphincter preservation were older, male, black, used Medicaid insurance, or lived in lower income zip codes. [ABSTRACT FROM AUTHOR]

Currently, surgeons specialize in colon and rectal surgery after a complete residency and certification in general surgery. The American Board of Surgery is proposing reorganization of surgical training; only two to four years of general surgery would be required followed by two to three years of specialization. The general surgery practice patterns of colon and rectal surgeons are unknown. The purposes of this study were to evaluate the current practice patterns of colon and rectal surgeons and to quantify the frequency and type of general surgical procedures performed. Active candidates, members, and fellows of The American Society of Colon and Rectal Surgeons were asked to complete an online survey. Results collected from November 18 to 26, 2004 were included. Data were self-reported. A total of 772 surgeons were included in the analysis; 7 percent were candidates, 29 percent were members, and 64 percent were fellows. Sixty-three percent had been practicing for 20 years or less and 64 percent were younger 50 years of age. Colon and rectal practice consisted of 28 percent abdominal surgery, 14 percent laparoscopic surgery, 28 percent anorectal surgery, and 30 percent endoscopy. Fifty-six percent of colon and rectal surgeons reported performing general surgery procedures with an average of 25 percent of their practice being general surgery. The most common procedures were herniorrhaphy (87 percent), cholecystectomy (76 percent), and appendectomy (33 percent). The most common reasons for general surgery practice were practice (52 percent) and emergency room requirements (43 percent). Currently, colon and rectal surgeons perform general surgery procedures in clinical practice. If general surgery residency of future trainees is shortened, the types of procedures colon and rectal surgeons will be competent to perform may need to be redefined. This will have profound implications on training programs, certification requirements, and future practice patterns. [ABSTRACT FROM AUTHOR]

Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation. Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles’ operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H2-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap. During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 ( P < 0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 ( P < 0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6–40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux. Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy. [ABSTRACT FROM AUTHOR]

Clostridium difficile enteritis is a rare infection, with less than a dozen cases reported in the literature. We present a case of a patient with total proctocolectomy and ileostomy, developing Clostridium difficile infection of small bowel. We discuss the role of Clostridium difficile toxins and review previously reported cases of Clostridium difficile enteritis after total colectomy. A 65-year-old male with a history of total proctocolectomy and ileostomy 30 years previously had purulent ileostomy drainage and septic shock. The patient was recently treated with intravenous piperacillin, tazobactam, and levofloxacin for aspiration pneumonia in the previous admission. Ileostomy stool cultures tested positive for Clostridium difficile toxin A, and the patient was promptly treated with intravenous metronidazole. The patient was aggressively resuscitated and treated, recovered from the enteritis and shock, but died of pulmonary complications after a prolonged hospitalization. Review of previously reported cases of Clostridium difficile enteritis showed a high mortality rate. We attribute this to delayed diagnosis secondary to rarity of this illness. Some patients were diagnosed only after pseudomembranes in small-bowel segments were found at autopsy. This rare disease entity is firmly established among the differential diagnosis to clinicians treating patients with total proctocolectomy. [ABSTRACT FROM AUTHOR]

Inflammation, villous atrophy, colonic metaplasia, and dysplasia have been observed within the mucosa of ileal pelvic pouches after restorative proctocolectomy. This study was designed to determine the prevalence of mucosal dysplasia in ileal pouch and any associated risk factors. Prospectively registered patients having restorative proctocolectomy were recruited. A cross-sectional study was performed using a questionnaire focusing on disease history, functional results, and pouchitis after surgery. Participants underwent screening endoscopic pouch examination using sigmoidoscopy. Mucosal biopsies were taken from six specific locations in the pouch from proximal ileal-pouch (inflow) to ileoanal anastomosis. All biopsies were performed under strict surveillance protocol regardless of patients’ symptoms. Biopsies were interpreted by two pathologists unaware of each other’s report. A total of 138 patients completed the protocol. Colectomy specimens from restorative proctocolectomy showed chronic ulcerative colitis in 118 (85.6 percent), familial adenomatous polyposis in 10 (7.2 percent), Crohn’s colitis in 2 (1.4 percent), and indeterminate colitis in 8 (5.8 percent) patients. Twenty-two patients (18.3 percent) had dysplasia and eight (6.7 percent) had invasive cancer found in colectomy specimens after restorative proctocolectomy. Median interval between proctocolectomy and pouch biopsy was 5.4 years. Inflammatory changes were present in a majority of specimens, but these did not correlate with clinical history of pouchitis. No villous atrophy was identified. Pouch biopsies from only one patient were indefinite for dysplasia. Subsequent biopsies were negative. Clinical and microscopic evidence of ileal-pouch inflammation is common. Ileal-pouch mucosal dysplasia is uncommon, occurring in only 1 of 138 patients. Villous atrophy and colonic metaplasia were not observed in this series. Routine pouch surveillance with biopsies may not be warranted. [ABSTRACT FROM AUTHOR]

This study was designed to assess the role of fecal lactoferrin and calprotectin as markers of intestinal inflammation in patients with Crohn’s disease who have undergone ileocolonic resection. Sixty-three patients who had undergone ileocolonic resection for Crohn’s disease with a median follow-up of 40.5 (range, 5–102) months were enrolled. Clinical examination and blood test were performed, and fecal lactoferrin and calprotectin levels were dosed. The predictors for fecal lactoferrin and calprotectin levels that resulted to be significant at the univariate analyses were included in two multiple regression analysis models. The mean lactoferrin level was 21 ± 3.9 μg/g and the mean calprotectin fecal level was 247 ± 22.7 ng/ml. C-reactive protein levels ( P < 0.01), calprotectin levels ( P < 0.01), and the presence of clinical recurrence ( P = 0.04) resulted to be independent predictors of lactoferrin levels. Only lactoferrin levels resulted to be an independent predictor for calprotectin fecal levels ( P < 0.01). Crohn’s disease patients maintain high fecal levels of lactoferrin and calprotectin at long-term follow-up after resection of the diseased bowel even in case of clinical remission. The significant correlation between the two fecal markers may be the expression of the ongoing intestinal inflammation. Only lactoferrin significantly correlated with C-reactive protein and showed a reliable threshold value for systemic inflammation. Lactoferrin fecal levels may be a reliable indicator for intestinal inflammation influencing the systemic inflammatory status. The third predictor of lactoferrin fecal level was the presence of episodes of clinical recurrence during the postoperative follow-up. [ABSTRACT FROM AUTHOR]

The article presents several abstracts related to colon and rectal surgery. They include "Prospective Multicenter Evaluation of Adverse Outcomes Following Treatment for Complicated Diverticular Disease" "Characterization of Colonic Polyps at Conventional (nonmagnifying) Colonoscopy After Spraying with 0.1% Indigo Carmine Dye" and "Flat Adenomas."

Scoring systems to predict mortality from surgery are important tools used to give information to the operator and patient and in the auditing of clinical practice. This study was designed to validate the recently developed the Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) scoring system in a single center for colorectal cancer surgery. We also analyzed whether albumin may have a role in the CR-POSSUM model. We compared this model with two other scoring systems: POSSUM and Portsmouth-POSSUM (P-POSSUM) models. In-hospital mortality was used as the outcome, and Hosmer-Lemeshow statistic was used to determine goodness of fit. Complete data were collected prospectively from 304 patients from 1990 to the present. The overall operative mortality was 6.5 percent. Observed to expected ratios were used to compare the scoring systems at a given predicted mortality. The overall observed to expected ratio was 1.25 for CR-POSSUM, 1.59 for P-POSSUM, and 3.37 for POSSUM. The CR-POSSUM model showed a good fit with the data (Hosmer-Lemeshow statistic, 3.86; P = 0.795) and the area under the receiver operator curve was 0.74. After correcting for factors used in the CR-POSSUM, logistic regression showed a significant correlation between albumin and mortality ( P = 0.016). We have shown that the CR-POSSUM model is an accurate predictor of outcome for major colorectal surgery. The POSSUM and P-POSSUM models over-predicted mortality. Albumin, which is not a factor included in these three systems, may be an important addition in improving the accuracy of the CR-POSSUM model. [ABSTRACT FROM AUTHOR]

Postoperative anastomotic leaks are one of the most devastating consequences of colorectal surgery. Diagnostic imaging for upper gastrointestinal anastomotic leaks has been evaluated and reported on extensively. No study has compared the utility and effectiveness of CT scans and water-soluble enemas for the identification of postoperative lower gastrointestinal anastomotic leaks. The present study was designed to evaluate and compare these two common radiographic imaging modalities in detecting lower gastrointestinal anastomotic leaks. A retrospective chart review was performed that identified 36 patients during a seven-year period who underwent reoperative surgery for a lower gastrointestinal anastomotic leak. Patient’s imaging studies were classified as positive if extravasation of contrast material was demonstrated. When negative, a study was retrospectively reviewed in an attempt to identify findings suggestive of an anastomotic leak. There were 36 patients identified with a postoperative lower gastrointestinal leak requiring surgical intervention. There were 28 of 36 patients (78 percent) re-explored on the basis of a radiologic study demonstrating an anastomotic leak. A total of 27 CT scans were performed, of which 4 (14.8 percent) were considered positive for an anastomotic leak. On review of the remaining negative CT scans, nine (33.3 percent) were considered descriptive positive with a large amount of fluid or air in the peritoneal cavity but without obvious extravasation of contrast. Eighteen patients were evaluated with a water-soluble enema and 15 (83.3 percent) demonstrated extravasation of contrast material. In the 26 patients with a distal anastomotic leak, 17 water-soluble enemas were performed, with 15 (88 percent) demonstrating a leak. In contrast, only 2 of 17 (12 percent) CT scans were positive in this group of patients ( P < 0.001). There were ten patients who initially had a CT scan followed by a water-soluble enema. Of these patients, eight of nine (88 percent) initially had a negative CT scan but were considered to be clinically suspicious of having an anastomotic leak and subsequently had a leak demonstrated on a water-soluble enema. Early intervention in patients who develop an anastomotic leak can be shown to improve the ultimate outcome, especially with respect to mortality. It is usually necessary to obtain objective tests of anastomotic integrity because of the nonspecificity of clinical signs. Our study supported the superiority of water-soluble enema to CT imaging in patients in whom both modalities were used. This difference was most pronounced for distal anastomotic leaks, whereas no radiologic imaging study proved effective in evaluating proximal anastomoses. [ABSTRACT FROM AUTHOR]