Search

Little is known about the long-term functional outcomes of restorative proctocolectomy.The aim of this study was to examine ileoanal pouch outcomes 20 and 30 years postoperatively.This is a retrospective case series.This study was conducted at a tertiary care referral center.Patients who underwent restorative proctocolectomy between 1980 and 1994 were identified. Those with ≥20 years of in-person follow-up were included.Pouch function, pouchitis, anal stricture, and pouch failure rates were analyzed.A total of 203 patients had ≥20 years of follow-up. Of those, 71 had ≥30 years of follow-up. Initial diagnoses included ulcerative colitis (83%), indeterminate colitis (9%), familial adenomatous polyposis (4%), and Crohn's disease (3%). Twenty-one percent of those with ulcerative or indeterminate colitis later transitioned to Crohn's disease. Mean daily stool frequency was 7 (IQR 6-8), 38% experienced seepage, 31% had anal stenosis, 47% experienced pouchitis, and 18% had pouch failure. Over time, stool frequency increased in 41% of patients, stayed the same in 43%, and decreased in 16%. Patients older than 50 years at the time of construction had more daily bowel movements (median 8 vs 6; p = 0.02) and more seepage (77% vs 35%; p = 0.005) than those younger than 50 years. Patients with Crohn's disease had higher stool frequency (median 8 vs 6; p0.001) and higher rates of anal stenosis (44% vs 26%; p = 0.02), pouchitis (70% vs 40%; p0.001), and pouch failure (38% vs 12%; p0.001) compared to non-Crohn's patients. Patients with ≥30 years of follow-up had similar function as those with 20-30 years of follow-up.This was a retrospective, single-institution study. Only 35% of pouches created during the study period had20 years of follow-up.Most patients maintain reasonably good function and retain their pouches after 20 years. Over time, stool frequency and seepage increase. Older age and Crohn's disease are associated with worse outcomes. See Video Abstract at http://links.lww.com/DCR/B801.ANTECEDENTES:se sabe poco sobre los resultados funcionales a largo plazo de la proctocolectomía restauradora.OBJETIVO:El objetivo de este estudio fue examinar los resultados del reservorio ileoanal 20 y 30 años después de la operación.DISEÑO:Serie de casos retrospectiva.ENTORNO CLÍNICO:Centro de referencia de atención terciariaPACIENTES:Se identificaron pacientes que se sometieron a proctocolectomía restauradora entre 1980 y 1994. Se incluyeron aquellos con ≥20 años de seguimiento en persona.PRINCIPALES MEDIDAS DE VALORACIÓN:Se analizaron la función, inflamación, tasas de falla del reservorio y estenosis anal.RESULTADOS:Un total de 203 pacientes tuvieron ≥20 años de seguimiento. De ellos, 71 tenían ≥30 años de seguimiento. Los diagnósticos iniciales incluyeron colitis ulcerosa (83%), colitis indeterminada (9%), poliposis adenomatosa familiar (4%) y enfermedad de Crohn (3%). El 21% de las personas con colitis ulcerosa o indeterminada pasaron posteriormente a la enfermedad de Crohn. La frecuencia promedio de las deposiciones diarias fue de 7 (rango intercuartil 6-8), el 38% experimentó filtración, el 31% tuvo estenosis anal, el 47% experimentó pouchitis y el 18% tuvo falla del reservorio. Con el tiempo, la frecuencia de las deposiciones aumentó en el 41% de los pacientes, se mantuvo igual en el 43% y disminuyó en el 16%. Los pacientes mayores de 50 años en el momento de la construcción tenían más evacuaciones intestinales diarias (media 8 vs 6, p = 0,02) y más filtraciones (77% vs 35%, p = 0,005) que los menores de 50 años. Los pacientes con enfermedad de Crohn tenían mayor frecuencia de deposiciones (media 8 vs 6, p0,001) y tasas más altas de estenosis anal (44% vs 26%, p = 0,02), inflamacion (70% vs 40%, p0,001) y falla del reservorio (38% frente a 12%, p0,001) en comparación con pacientes que tenian enfermedad de Crohn. Los pacientes con ≥30 años de seguimiento tuvieron una función similar a aquellos con 20-30 años de seguimiento.LIMITACIONES:Este fue un estudio retrospectivo de una sola institución. Solo el 35% de los reservorios creados durante el período de estudio tuvieron más de 20 años de seguimiento.CONCLUSIONES:La mayoría de los pacientes mantienen una función razonablemente buena y conservan el reservorio después de 20 años. Con el tiempo, la frecuencia de las deposiciones y la filtración aumentan. La vejez y la enfermedad de Crohn se asocian con peores resultados. Consulte Video Resumen en http://links.lww.com/DCR/B801. (Traducción - Dr. Ingrid Melo).

Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission.This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection.This is a retrospective review of a prospectively compiled single-institution database.From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included.The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection.Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value.This study was limited by its retrospective design and because all patients were treated at a single center.Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.

Colon and rectal surgery as a separate and identifiable specialty dates back to the early 1900s. Development of training programs, beginning as proctology preceptorships and evolving to residency programs recognized by the Accreditation Council for Graduate Medical Education, demonstrate the value of the unwavering dedication of the founders of the field. Similarly, creation of an independent Board with its own certification procedures has maintained the independence and integrity of the specialty despite external pressures to return to general surgery. Both the development of the board and training programs are reviewed in detail.

The impact of process improvement through surgeon feedback on outcomes is unclear.We sought to evaluate the effect of biannual surgeon-specific feedback on outcomes and adherence to departmental and Surgical Care Improvement Project process measures on colorectal surgery outcomes.This was a retrospective analysis of prospectively collected 100% capture surgical quality improvement data.This study was conducted at the department of colorectal surgery at a tertiary care teaching hospital from January 2008 through December 2013.Each surgeon was provided with biannual feedback on process adherence and surgeon-specific outcomes of urinary tract infection, deep vein thrombosis, surgical site infection, anastomotic leak, 30-day readmission, reoperation, and mortality. We recorded adherence to Surgical Care Improvement Project process measures and departmentally implemented measures (ie, anastomotic leak testing) as well as surgeon-specific outcomes.We abstracted 7975 operations. There was no difference in demographics, laparoscopy, or blood loss. Adherence to catheter removal increased from 73% to 100% (p0.0001), whereas urinary tract infection decreased 52% (p0.01). Adherence to thromboprophylaxis administration remained unchanged as did the deep vein thrombosis rate (p = not significant). Adherence to preoperative antibiotic administration increased from 72% to 100% (p0.0001), whereas surgical site infection did not change (7.6%-6.6%; p = 0.3). There were 2589 operative encounters with anastomoses. For right-sided anastomoses, the proportion of handsewn anastomoses declined from 19% to 1.5% (p0.001). For left-sided anastomoses, without diversion, anastomotic leak testing adherence increased from 88% to 95% (p0.01). Overall leak rate decreased from 5.2% to 2.9% (p0.05).Concurrent process changes make isolation of the impact from individual process improvement changes challenging.Nearly complete adherence to process measures for deep vein thrombosis and surgical site infection did not lead to measureable outcomes improvement. Process measure adherence was associated with decreased rate of anastomotic leak and urinary tract infection. Biannual surgeon-specific feedback of outcomes was associated with improved process measure adherence and improvement in surgical quality.

The aim of this article is to evaluate geographic variation in the incidence of diverticulitis and examine behavioral and environmental factors associated with high rates of diverticulitis across the United States. We used state hospital discharge data from 20 states to determine rates of inpatient diverticulitis from January 2002 to December 2004 at patient's county of residence. Next, we merged the county level data with behavioral and environmental survey data from the Behavioral Risk Factor Surveillance System (BRFSS). Finally, we determined the association between behavioral and environmental factors (i.e., teeth removal, dental cleaning, air quality, smoking, alcohol, vaccine, vitamins, and mental health) and high rates of diverticulitis. From January 1, 2002, to December 31, 2004, a total of 345,216 hospitalizations for acute diverticulitis were recorded for 1,055 counties. We identified rates of diverticulitis that ranged from 35.4 to 332.7 per 100,000 population. On univariate analysis, high diverticulitis burden was associated with regions of the country with substantial tooth loss from dental disease (45.8% for high diverticulitis counties vs. 37.5% for low diverticulitis counties; p = 0.0001). There is considerable variability in diverticulitis cases by county of residence across the nation. Potential triggers of diverticulitis may be associated with tooth removal and sun exposure.

The aim of this study was to determine whether there is an association between appendicitis and diverticulitis.This study is a retrospective cohort analysis.This study was conducted in a subspecialty practice at a tertiary care facility.We examined the rate of appendectomy among 4 cohorts of patients: 1) patients with incidentally identified diverticulosis on screening colonoscopy, 2) inpatients with medically treated diverticulitis, 3) patients who underwent left-sided colectomy for diverticulitis, and 4) patients who underwent colectomy for left-sided colorectal cancer.There were no interventions.The primary outcome measured was the appendectomy rate.We studied a total of 928 patients in this study. There were no differences in the patient characteristics of smoking status, nonsteroidal use, or history of irritable bowel syndrome across the 4 study groups. Patients with surgically treated diverticulitis had significantly more episodes of diverticulitis (2.8 ± 1.9) than the medically treated group (1.4 ± 0.8) (p0.0001). The rate of appendectomy was 8.2% for the diverticulosis control group, 13.5% in the cancer group, 23.5% in the medically treated diverticulitis group, and 24.5% in the surgically treated diverticulitis group (p0.0001). After adjusting for demographics and other clinical risk factors, patients with diverticulitis had 2.8 times higher odds of previous appendectomy (p0.001) than the control groups.The retrospective study design is associated with selection, documentation, and recall bias.Our data reveal significantly higher appendectomy rates in patients with a diagnosis of diverticulitis, medically or surgically managed, in comparison with patients with incidentally identified diverticulosis. Therefore, we propose that appendicitis and diverticulitis share similar risk factors and potentially a common pathological link.

Colon and rectal surgery as a separate and identifiable specialty dates back to the early 1900s. Development of training programs, beginning as proctology preceptorships and evolving to residency programs recognized by the Accreditation Council for Graduate Medical Education, demonstrate the value of the unwavering dedication of the founders of the field. Similarly, creation of an independent Board with its own certification procedures has maintained the independence and integrity of the specialty despite external pressures to return to general surgery. Both the development of the board and training programs are reviewed in detail.

BACKGROUND Efforts to improve the quality of surgical care and reduce morbidity and mortality have resulted in outcomes reporting at the service and institutional level. Surgeon-specific outcomes are not readily available. OBJECTIVE The aim of this study is to compare surgeon-specific outcomes from the National Surgical Quality Improvement Program and 100% capture institutional quality data. DESIGN We conducted a cohort study evaluating institutional and surgeon-specific outcomes following colorectal surgery procedures at 1 institution over 5 years. PATIENTS All patients who underwent an operation by a colorectal surgeon at Lahey Hospital & Medical Center from January 1, 2008 through December 31, 2012 were identified. MAIN OUTCOME MEASURES Thirty-day mortality, reoperation, urinary tract infection, deep vein thrombosis, pneumonia, superficial surgical site infection, and organ space infection were the primary outcomes measured. ANALYSIS We compared annual and 5-year institutional and surgeon-specific adverse event rates between the data sets. In addition, we categorized individual surgeons as low-outlier, average, or high-outlier in relation to aggregate averages and determined the concordance between the data sets in identifying outliers. Concordance was designated if the 2 databases classified outlier status similarly for the same adverse event category. RESULTS In the 100% capture institutional data, 6459 operative encounters were identified in comparison with 1786 National Surgical Quality Improvement Program encounters (28% sampled). Annual aggregate adverse event rates were similar between the institutional data and the National Surgical Quality Improvement Program. For annual surgeon-specific comparisons, concordance in identifying outliers between the 2 data sets was 51.4%, and gross discordance between outlier status was in 8.2%. Five-year surgeon-specific comparisons demonstrated 59% concordance in identifying outlier status with 8.2% gross discordance for the group. LIMITATIONS The inclusion of data from only 1 academic referral center is a limitation of this study. CONCLUSIONS Each surgeon was identified as a "high outlier" in at least 1 adverse event category. Comparisons at the annual and 5-year points demonstrated poor concordance between our 100% capture institutional data and the National Surgical Quality Improvement Program data.

There are various surgical techniques used treat anal fistulas. The adoption and success rates of newer techniques have not been clearly established.The purpose of this study was to determine the healing rate after operations for anal fistulas in New England colorectal surgery practices.We conducted a retrospective review of a prospectively collected database.The study was conducted at colorectal surgery practices in New England.A prospective, multicenter registry was created by the New England Society of Colon and Rectal Surgeons. Surgeons were invited to collect data prospectively regarding patients operated on for anal fistulas between January 1, 2011, and August 1, 2013. Fistula classification, surgical intervention, continence scores, and healing were determined by the treating surgeon.Operation for anal fistula was performed.We measured the proportion of patients with healed fistulas at 3 months.Sixteen surgeons submitted data regarding 240 operations for fistula with curative intent. Mean patient age was 45 ± 14 years. A total of 158 patients (66%) were men, and 110 (46%) had undergone an anorectal operation. Twenty-nine (12%) had Crohn's disease. The healing rates of fistulotomy, advancement flap, and fistula plugs at 3 months were 94% (95% CI, 89-97), 60% (95% CI, 33-77), and 20% (95% CI, 5-50). The healing rate of the ligation of intersphincteric fistula tract procedure at 3 months was 79% (95% CI, 65-88). Hospital site was the only variable associated with healing (p0.05). Hospitals that performed more ligation of intersphincteric fistula tract procedures had higher healing rates at 3 months (p0.0001).This study was limited by selection bias and reporting bias.A wide variety of techniques are used to treat anal fistulas in our region. Fistulotomy continues to have excellent results. There has been enthusiastic early adoption of the ligation of intersphincteric fistula tract technique. Early healing rates after the ligation of intersphincteric fistula tract procedure appear to be excellent.

Validated risk adjustment programs do not use patient diagnosis as a potential covariate in the evaluation of organ space infections.We hypothesized that patient diagnosis is an important risk factor for organ space infection after colorectal resections.We conducted a retrospective cohort study abstracting data from the American College of Surgeons National Surgical Quality Improvement Program from January 2005 through December 2009.Patients who underwent 1 of 3 types of colorectal resections (ileocolostomy, partial colectomy, and coloproctostomy) were identified by the use of Current Procedural Terminology codes. We excluded patients with concomitant formation of diverting or end stoma.The primary outcome measured was organ space infection.Validated risk adjustment models were used with the addition of diagnostic codes.We identified 52,056 patients who underwent a colorectal resection of whom 1774 patients developed an organ space infection (3.4%) and 894 (50.2%) returned to the operating room for further surgery. For ileocolostomy, operations for endometriosis (OR, 7.8; 95% CI, 1.7-36.6) and intra-abdominal fistula surgery (OR, 3.0; 95% CI, 1.5-6.0) were associated with increased risk of organ space infection. For partial colectomy, operations for intra-abdominal fistula surgery (OR, 2.3; 95% CI, 1.2-4.3), IBD (OR, 2.5; 95% CI, 1.6-3.8), and bowel obstruction (OR, 1.8; 95% CI, 1.2-2.6) were associated with an increased risk of organ space infection. For coloproctostomy, operations for malignant neoplasm (OR, 2.2; 95% CI, 1.1-4.3) and diverticular bleeding (OR, 3.1; 95% CI, 1.1-9.0) were associated with an increased risk of organ space infection.This study was limited by the retrospective study design.After adjustment for National Surgical Quality Improvement Program covariates, intra-abdominal fistula, endometriosis, and diverticular bleeding were the diagnoses associated with the highest risk of organ space infection following colorectal resections.

There has been increased attention focused on reducing postoperative length of stay and mortality following colorectal surgery. We sought to identify adverse events associated with prolonged length of stay and mortality. We evaluated postoperative “adverse events,” prolonged length of stay, and mortality within 30 days of colorectal surgery in the National Surgical Quality Improvement Program (NSQIP) hospitals from January 2005 through December 2008. We then used multivariate models to establish the associations between adverse events and prolonged length of stay and mortality. A total of 54,237 patients underwent colorectal surgery: 39,980 (74 %) experienced no postoperative adverse events, while 14,257 (26 %) experienced one or more adverse events. Length of stay was prolonged (longer than 10 days) in 38 % of patients who experienced a postoperative adverse event and in 15 % of patients without events. Mortality increased with the number of postoperative adverse events. In multivariate models including preoperative comorbidity, patient risk factors, and adverse events, patients who experienced a cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure were at highest odds of dying within 30 days of surgery. Patients with cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure are at highest risk of mortality following colorectal surgery.

Data comparing surgical outcomes following abdominal and transperineal approaches for rectal prolapse are limited.We sought to identify differences in postoperative complications following abdominal vs transperineal approaches to rectal prolapse.We studied a retrospective cohort in the American College of Surgeon's National Surgical Quality Improvement Program from January 2005 through December 2008.We identified all patients who underwent surgical treatment for rectal prolapse.We compared surgical outcomes of standard abdominal approaches compared with standard transperineal approaches to rectal prolapse.The primary outcomes measured were the validated morbidity outcomes and 30-day mortality.During the study period, 1485 patients underwent rectal prolapse surgery (706 abdominal and 779 transperineal). Patients treated with abdominal approaches had significantly higher rates of infectious (9.8% vs 3.7%) and overall (12.9% vs 7.6%) complications in comparison with those treated with transperineal approaches. On multivariate analysis, risk factors for overall complications were ASA class 4 (OR 6.4) and abdominal surgery (OR 2.3), whereas an albumin level of ≥ 2.5 was protective (OR 0.05). Significant predictors of infectious complications were ASA class 4 (OR 7.5), BMI25 (OR 1.8), and rectal prolapse surgery performed with an abdominal approach (OR 2.8).The retrospective design introduces potential selection bias.Abdominal surgery for rectal prolapse is a predictor of both infectious and overall complications. Patients with significant comorbidities or a high BMI are at particularly high risk for complications and may be better suited for a transperineal rather than abdominal approach for the treatment of rectal prolapse.

Aim We sought to identify the rate of re-operation after an index colorectal surgical procedure and potential contributing risk factors. Method This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008. Results From a total cohort of 635 265 patients included in the National Surgical Quality Improvement Program over the 4-year study period, we identified 54 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P

There is wide variation in surgical care for rectal cancer in the United States.This study aimed to assess the differences in individual surgeon procedural profiles that might explain variations in the rates of restorative vs nonrestorative proctectomy for rectal cancer.This study was a retrospective examination of a cohort derived from trackable state hospital discharge data from 11 states.We identified all patients with rectal cancer that underwent restorative proctectomy (sphincter-sparing surgery) vs nonrestorative proctectomy (colostomy formation) over a 24-month study period (January 1, 2003 through December 31, 2004).We developed an inpatient procedural profile of each treating surgeon's practice across general surgery procedure codes and summed the number of restorative vs nonrestorative proctectomies for rectal cancer by surgeon.The primary outcome measures were nonrestorative proctectomy, mortality, and length of stay.A total of 7519 proctectomies were performed for rectal cancer by 2588 surgeons. During the 24-month study period, 1003 (38.8%) surgeons performed only nonrestorative procedures for rectal cancer. On multivariate analysis, the likelihood that a surgeon performed only nonrestorative procedures was increased if that surgeon performed more integumentary procedures and decreased if the surgeon performed at least one ileoanal pouch procedure or more anorectal procedures. Patients who underwent proctectomy by surgeons who performed only nonrestorative procedures had significantly higher mortality (2.5 ± 0.7%) and longer length of stay (11.3 ± 8.8 days) in comparison with those patients treated by surgeons who performed both restorative and nonrestorative procedures (1.3 ± 0.3% mortality and 9.2 ± 6.9 days, P.001 for both analyses). The volume of proctectomy performed significantly affected all analyses.: The retrospective design introduces potential selection bias.Over a 24-month period, 38.8% of surgeons performed only nonrestorative procedures for rectal cancer. These surgeons did not regularly perform anorectal or ileoanal pouch procedures, suggesting that they may not have a focus on colorectal disease in their practice; they had significantly higher mortality and length of stay for their patients who underwent proctectomy for rectal cancer.

In this study, we analyzed temporal trends in anti-adhesion barrier application and admission rates for small bowel obstruction. We used data from the Nationwide Inpatient Sample and identified patients with ICD-9 codes for “application or administration of anti-adhesion barrier substances” from October 2002 through December 2007. Next, we identified cases of bowel obstruction coded from January 1997 through December 2007. We then used Kendall correlation analyses and the Joinpoint regression program to evaluate changes in trends. From October 1, 2002 through December 31, 2007, a total of 28,014 patients had an anti-adhesion barrier substance applied. During the study period, application of anti-adhesion barriers increased from 0.7 applications per 100,000 to 2.6 applications per 100,000 population (Joinpoint and Kendall; P < 0.002). Since 1997 there has been a steady rise in hospitalizations for bowel obstruction, increasing from 18.3 cases per 100,000 to 19.8 cases per 100,000 population (Joinpoint and Kendall; P < 0.002). In conclusion, the application of anti-adhesion barriers has increased significantly since 2002, yet bowel obstructions continue to be a major health problem.

Geographic variability in the use of restorative proctectomy for rectal cancer has been described throughout the United States. We examined factors associated with high rates of colostomy formation after proctectomy for rectal cancer across US counties.We used state hospital discharge data from 21 states to determine county rates of restorative proctectomy vs nonrestorative proctectomy (ie, colostomy) for rectal cancer. We merged the county-level data with 1) tumor characteristics from Surveillance Epidemiology and End Results data; 2) number of specialty surgeons in the American Society of Colon and Rectal Surgeons and Society of Surgical Oncology; 3) county socioeconomic variables from census data; 4) colorectal cancer-screening rates from Medicare; and 5) hospital characteristics from the American Hospital Association. We then determined factors associated with high rates of colostomy formation (60%) after proctectomy for rectal cancer across counties.From January 1, 2002, to December 31, 2004, a total of 19,912 proctectomies were performed for cancer in 1050 counties, of which 489 had adequate sample size for evaluation. Based on county of residence information, nonrestorative proctectomy with colostomy was performed in greater than 60% of all patients with rectal cancer in 26% (n = 125) of counties. On multivariate analysis, more specialty surgeons (OR = 0.70; CI = 0.51-0.96) were protective against colostomy formation at the county level.The use of restorative techniques in rectal cancer surgery varies based on access to specialty colorectal cancer surgeons. Population-based directives are needed to standardize care for rectal cancer across the United States.

The ultimate fate of the leaking intestinal anastomosis is unknown. We sought to analyze long-term outcomes of anastomotic leak with an emphasis on identifying the likelihood of re-establishing intestinal continuity and the potential for releak with corrective surgery.All consecutive subjects treated for clinical anastomotic leak from January 2001 through December 2007 were retrospectively reviewed. Patients were stratified by management of leak: (1) drainage alone, (2) proximal loop diversion, (3) repair/revision without diversion, (4) end stoma, or (5) tube enterostomy. We then determined management of anastomotic leak, mortality, corrective procedures, releak, and re-establishment of intestinal continuity.In a database of 2,627 intestinal procedures, 79 patients had 88 anastomotic leaks with a final overall mortality of 10.1%. The aggregate rate of re-establishment of intestinal continuity was lowest for the patients treated by end stoma (44.4%) as compared to other initial management options (p0.01). Of the patients who survived their initial anastomotic leak, 20.5% had another leak (releak).Patients who underwent resection of the leaking anastomosis and end stoma or proximal loop diversion have a high rate of long-term fecal diversion. The proportion of patients who experience an anastomotic releak is substantial following further corrective surgery to re-establish intestinal continuity.

Operative results of volvulus are largely unknown because of infrequent diagnosis.We examined the results of operative intervention for colonic volvulus.We merged trackable data from the California Inpatient Database with Supplemental Files for Revisit Analyses between January 1, 2005, and December 31, 2007.Trackable data from California discharge records.We identified all of the patients with colonic volvulus who underwent 1 of 4 surgical procedures, including manipulation/fixation of the colon, right colectomy, left colectomy, or total colectomy.During the 36-month study period, we identified recurrence risk, recurrence requiring reoperation, time to reoperation, stoma formation, disposition on discharge, and in-hospital mortality. Fisher exact, χ(2), and ANOVA tests were used when appropriate.We identified 2141 patients with colonic volvulus who were undergoing intraoperative manipulation/fixation of the colon (n = 209 (12%)), right (n = 728 (41%)), left (n = 781 (44%)), or total colectomy (n = 56 (3%)). Patients treated with intraoperative manipulation/fixation were younger, more likely to be women, and more likely to have private insurance. Patients who underwent total colectomy had the highest risk of mortality (21%), highest risk of stoma creation (64%), and longest length of stay (18 days); were more likely to be readmitted (9%); and were the most likely to be discharged to a skilled nursing facility (48%). Patients treated with intraoperative manipulation/fixation had the lowest mortality, risk of stoma formation, length of stay, and likelihood of discharge to skilled nursing facility but the highest risk of subsequent procedures for volvulus (26%) over a follow-up ranging from 0 to 687 days.This study was limited by retrospective study design, heterogeneous patient factors, and inability to identify the time of last follow-up.The majority of patients with volvulus underwent a resectional procedure. A subset without resection had favorable initial outcomes but remained at high risk for subsequent procedures. There may be a potential role for evaluating intraoperative manipulation/fixation in a small subset of patients with colonic volvulus.

Hand-assisted laparoscopic colectomy is thought to facilitate colonic mobilization while maintaining the benefits of laparoscopic surgery. Although previous studies of hand-assisted colectomy have focused on segmental colonic resection, the use of hand-assisted laparoscopic restorative proctocolectomy has not been investigated. This study evaluated the effectiveness of hand-assisted laparoscopic approach compared with a conventional laparoscopic method in patients undergoing restorative proctocolectomy. From a prospective database, a consecutive series of patients were identified undergoing conventional and hand-assisted laparoscopic restorative proctocolectomy and results were compared. Twenty-three patients, comprising 10 hand-assisted and 13 conventional laparoscopic patients, were identified. Patient characteristics, perioperative parameters, and outcomes were assessed. Both groups were well matched with no differences in age, gender, body mass index, operative indication, diagnosis, comorbidity, or steroid usage. There were no differences among incision size between the hand-assisted (8 (range, 8–20) cm) and conventional laparoscopic cases (8 (range, 5–10) cm). The median operative time was significantly shorter in the hand-assisted group (247 (range, 210–390) minutes) compared with the conventional laparoscopic group (300 (range, 240–400) minutes; P < 0.01). The length of stay was similar between groups (hand-assisted: 4 (range, 3–13) days vs. conventional: 6 (range, 4–17) days). Complications occurred in four hand-assisted patients (40 percent; 2 ileus, mechanical obstruction, and dehydration) and in four patients undergoing conventional laparoscopic method (31 percent; 2 anastomotic leak, ileus, and mechanical obstruction). Compared with conventional laparoscopic restorative proctocolectomy, the hand-assisted method resulted in a significant reduction in operative time without detriment to bowel function, length of stay, or patient outcome. The hand-assisted approach to restorative proctocolectomy is likely to replace conventional laparoscopic methods as the preferred laparoscopic approach for this technically challenging procedure.

BACKGROUND: Chromosome 3q gain has been identified in human papillomavirus–infected cervical cancer cells. OBJECTIVE: We sought to identify the presence of chromosomal 3q gain in anal neoplasia. DESIGN: This was a retrospective cohort. SETTINGS: The study was conducted in a group colorectal surgery practice. PATIENTS: Fifty-two patients with no dysplasia, low-grade dysplasia, high-grade dysplasia, or anal cancer were studied. INTERVENTIONS: Pairs of biopsy specimens were paraffin embedded and reviewed. One of each slide pair was stained with hematoxylin and eosin and the second processed for fluorescence in situ hybridization. The hybridized set was deparaffinized first and then hybridized with a probe for the chromosome 3q26 region. Then, slides were scanned using an automated fluorescence microscopy system that analyzed defined areas of the tissue to enumerate all of the nuclei for hybridized probe signals to detect chromosome 3q gain. MAIN OUTCOME MEASURES: We measured for gain in chromosome 3q26. RESULTS: We identified chromosome 3q gain in 7 (78%) of 9 patients with squamous-cell cancer, 8 (53%) of 15 high-grade dysplasia samples, 0 of 12 low-grade dysplasia samples, and 0 of 16 samples with no dysplasia. The sensitivity for high-grade or invasive neoplasia was 58%, with a specificity of 100%. The positive predictive value of the test was 100% for detecting high-grade dysplasia and/or squamous-cell cancer from no dysplasia, and the negative predictive value of the test was 62%. LIMITATIONS: This study was limited by its small sample size and retrospective design. CONCLUSIONS: Chromosome 3q gain represents an important shared pathway to tumorigenesis in cervical and anal neoplasia. Multiple potential diagnostic roles exist for this easily performed test in the evaluation of anal neoplasia.

The objective of this study was to identify clinical leak in diverted colorectal anastomoses. Cohort analysis. The study was conducted in a subspecialty practice at a tertiary care facility. Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012. No intervention was applied. Clinical anastomotic leak. Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing. In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.

PURPOSE: The main impetus for a patient with familial adenomatous polyposis to choose colectomy with ileorectal anastomosis over ileal pouch-anal anastomosis is the better functional result. However, does better functional result necessarily translate into better overall quality of life? Previous studies of other diseases have demonstrated no such correlation. This study was performed to determine whether any relationship exists between functional result and quality of life in patients with familial adenomatous polyposis after ileorectal anastomosis and ileal pouch-anal anastomosis. METHODS: All patients with familial adenomatous polyposis who underwent colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis from 1980 to 1998 were studied. Functional data were obtained by questionnaire. Health-related quality of life was assessed by two validated instruments, the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey, which measure physical and mental functioning and eight separate health-quality dimensions, including health perception, physical and social functioning, physical and emotional role limitations, mental health, bodily pain, and energy or fatigue. RESULTS: Data were obtained in 44 of 68 patients, 14 with ileorectal anastomosis and 30 with ileal pouch-anal anastomosis. No differences were demonstrated between the two groups for patient age, mean follow-up time, and mean patient age at operation. Functional results were worse for the ileal pouch-anal anastomosis groupvs. the ileorectal anastomosis group in number of bowel movements per day (7.5vs. 5.2;P

Diverticular disease of the colon: A century-old problem David Schoetz; Diseases of the Colon & Rectum

PURPOSE: This study investigated the functional significance of perineal complications after ileal pouch-anal anastomosis. METHODS: Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi-squared and Fisher's exact probability tests. RESULTS: Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications. CONCLUSIONS: An appreciable number of perineal complications occur after ileal pouch-anal anastomosis. Pouch-perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch-anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.

PURPOSE: Assessment of sustained voluntary contraction of the external sphincter is helpful in evaluating the patient who has a defecation disorder on presentation. A new index of external sphincter function is described. METHOD: A prospective registry of patients referred for computerized anal manometry using standard protocols was reviewed. Patients were grouped by primary symptoms; those with overlapping complaints were excluded. The rate of fatigue, defined as the change in stationary squeeze over a 40-second period of voluntary contraction, was calculated by linear regression analysis. Fatigue rate index, a calculated measure of time necessary for the external sphincter to become completely fatigued, was determined to permit comparison of external sphincter fatigue in patients with different complaints. RESULTS: Twenty-six healthy volunteers (15 women; mean age, 45 years), 33 patients with a primary complaint of anal seepage (13 women; mean age, 53 years), 75 patients with gross incontinence (61 women; mean age, 53 years), and 49 patients with severe constipation (41 women; mean age, 45 years) were evaluated. Mean resting and squeeze pressures were 55 mmHg and 107 mmHg for volunteers, 37 mmHg and 97 mmHg for patients with seepage, 30 mmHg and 49 mmHg for incontinent patients, and 56 mmHg and 93 mmHg for constipated patients. Pudendal neuropathy, as evidenced by a prolonged pudendal nerve terminal motor latency (>2.4 ms), was identified in 13 percent of volunteers, 32 percent of patients with seepage, 54 percent of incontinent patients, and 38 percent of constipated patients. Mean fatigue rate index was 3.3 minutes for volunteers, 2.3 minutes for seepage patients, 1.5 minutes for incontinent patients, and 2.8 minutes for constipated patients. Compared with volunteers and patients with seepage, the incontinent patients had a significantly shorter fatigue rate index (P

PURPOSE: The study contained herein used the database of the American Board of Colon and Rectal Surgery to demonstrate trends in colorectal practice from 1989 to 1996 and to compare the one-year technical experience of a colorectal resident with the five-year totals of a general surgery resident. METHODS: Complete case lists from applicants for the American Board of Colon and Rectal Surgery's qualifying examination have been entered into a database. Similar data have been compiled from the Residency Review Committee for Surgery. RESULTS: From 1989 through 1996, 446,082 procedures have been listed by 417 colorectal residents, an average of 1,060 cases per resident. When contrasted with the operative experience of a general surgery resident, the colorectal resident performs substantially more anorectal operations, more endoscopic procedures, and more index abdominal operations in one year than the average general surgery resident performs in five years. CONCLUSIONS: When added to the required general surgery experience, one year of training in colorectal surgery trains a true subspecialist with unique expertise in the treatment of disorders of the colon, rectum, and anus.

PURPOSE: Fecal incontinence may occur in several forms. Although some patients are grossly incontinent, other patients experience only leakage. In patients with gross incontinence, severity can range from the mildest forms (limited to loss of control of flatus) to the most severe forms (involving loss of solid stool). This study was undertaken to determine which physiologic parameters differentiate female patients with incontinence of solid stool from patients with control of formed stool and incontinence limited to seep age. METHODS: Thirty-eight consecutive female patients with a primary complaint of seepage or solid stool incontinence were evaluated using water perfusion manometry, balloon inflation assessment of rectal sensitivity, and pudendal nerve terminal motor latency. A prospectively maintained database was used for collection of data. The findings in the two patient groups were compared with patients in a group of normal control individuals. Ages of the women in the three groups were similar. RESULTS: Both groups of patients demonstrated statistically significant (P < 0.05) decreases in rest and squeeze sphincter lengths, pressures, and pressure volumes compared with normal volunteers. The patients also had significantly more asymmetric highpressure zones and hypersensitive rectums. No significant difference between the two groups of incontinent patients could be identified using any of these parameters. Significant differences between the groups were found in pudendal nerve function. The distal rectoanal excitatory reflex was abnormal in 58.1 percent of grossly incontinent women compared with 28.6 percent of patients with leakage (P < 0.05). The majority of patients with leakage alone (65 percent) had normal pudendal nerve terminal motor latency, whereas only 22.6 percent of women with gross fecal incontinence had normal pudendal nerve terminal motor latency bilaterally (P = 0.01). CONCLUSIONS: Normal bilateral pudendal nerve function can partially compensate for abnormal sphincter symmetry and function, permitting women with grossly abnormal parameters to maintain control of bowel movements. It remains to be seen whether, with advancing age, patients with leakage will have development of slowed pudendal nerve conduction and, if so, whether their condition will progress to gross incontinence.

PURPOSE: In response to external pressure to achieve an idealized length of stay after colon resection, a study was designed to define perioperative factors that significantly impact average length of stay (ALOS). METHODS: We retrospectively reviewed the records of 226 patients undergoing open colon resection from 1988 to 1995 to determine the effects of age, type of procedure, nature of the procedure (electivevs.emergency), and postoperative course on ALOS. Statistics were calculated by Student'st-test, chisquared analysis, and analysis of variance. RESULTS: Average length of stay was 10 (range, 4–34) days, with a significant trend toward lower ALOS in recent years; ALOS in 1988 averaged 11 days, whereas in 1994, ALOS averaged 9 days (r2=0.118;P

BACKGROUND: Staged resection of the sigmoid colon has been the traditional strategy for treating patients who require nonelective surgery to manage complications of diverticular disease. Resection and primary anastomosis has not generally been recommended when the clinical setting is compromised by contiguous inflammation or inadequate mechanical cleansing of the colon because of concerns regarding the potential risk of anastomotic dehiscence. Although many reports have confirmed that intraoperative colonic lavage (ICL) is a safe method for relieving fecal loading of the colon to facilitate primary intestinal anastomosis in patients with mechanical obstruction of the distal colon, there is very limited experience with the use of this technique in treating acute inflammatory disorders of the colon. In this report, we present our results with ICL in the nonelective treatment of patients with complications of diverticulitis. METHODS: Records of all patients undergoing urgent operations at the Lahey Clinic to treat complications of diverticular disease from July 1987 to January 1996 were reviewed. RESULTS: Of 62 patients who required nonelective operations, 33 underwent ICL in an attempt to perform primary anastomosis. In five patients, the operation included creation of a colostomy. The indication for surgery was obstruction in 13 patients (39 percent), persistent abscess or phlegmon in 13 (39 percent), perforation in 6 patients (18 percent), and hemorrhage in 1 patient (3 percent). According to Hinchey's classification system, 18 patients had Stage I disease, 10 had Stage II, and 5 patients had Stage III disease. There were no patients with Stage IV disease. The single anastomotic complication in the series was responsible for the sole operative mortality. The morbidity rate of 42 percent, included three intraoperative complications (2 splenic injuries and 1 ureteral laceration), two intra-abdominal abscesses (6 percent), and six wound infections (18 percent). CONCLUSION: In our experience, ICL has proven to be a safe method for accomplishing single-stage resection of the colon in selected patients with diverticulitis who require an urgent operation. When there is no evidence of diffuse purulent or feculent peritonitis, we believe this is the preferred method for treating patients who are hemodynamically stable.

PURPOSE: Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb at the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy. METHODS: Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database of all patients who have undergone IPAA since 1980. Records of patients who were identified as having afferent limb obstruction as a cause of bowel obstruction after IPAA were reviewed. RESULTS: A total of 567 patients had undergone total proctocolectomy and ileoanal J-pouch at time of the study. Of 122 patients with one or more episodes of obstruction after IPAA, 48 required operative intervention. Afferent limb obstruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruction (4 of 6 patients). Contrast small-bowel series and enemas were suggestive of obstruction in four of six patients, the most consistent radiographic finding being small-bowel dilation to the level of the pouch inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterior to the pouch, causing acute angulation at the pouch inlet. Rather than risk injury to the pouch or its mesentery, the obstruction was bypassed by side-to-side anastomosis of the afferent limb to the pouch (enteroenterostomy) in five of six patients. One patient underwent ileostomy only because of technical considerations. Two patients required re-exploration and pexy of the afferent limb to the pelvic sidewall (pouchopexy) to relieve recurrent afferent limb obstruction. CONCLUSION: Afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from distal ileum to the pouch is safe and effective treatment. Because of the risk of recurrent afferent limb angulation, concurrent pouchopexy should be considered.

The aim of our study was to evaluate the effect of stoma creation on deep and superficial surgical site infections after an index colorectal surgical procedure. We designed a retrospective cohort study from the National Surgical Quality Improvement Program. We evaluated all patients who underwent colorectal surgery procedures from January 2005 to December 2009 with or without creation of a stoma and sought to identify the effect of stoma creation on deep and superficial surgical site infections. A total of 79,775 patients underwent colorectal procedures (laparoscopic 30.7 %, open 69.3 %), while 8,113 patients developed a surgical site infection (10.2 %). The univariate analysis revealed that surgical site infections were much more common in patients with a stoma compared to those with no stoma (11.8 % vs. 9.5 %, p

PURPOSE: This study was undertaken to determine the role of abnormal distal rectoanal excitatory reflex (RAER) as a marker of pudendal neuropathy and to compare results with pudendal nerve terminal motor latency (PNTML) and single fiber density (SFD) estimation. METHODS: Fifteen female patients (mean age, 47.1 (range, 20–70) years) referred to the pelvic floor laboratory with pelvic floor disorders (fecal incontinence, 13 patients; constipation, 2 patients) were evaluated prospectively with neurophysiologic tests and balloon reflex manometry for evidence of pudendal neuropathy. RESULTS: Pudendal nerve terminal motor latency provided evidence of pudendal neuropathy in ten patients (67 percent) and was normal in five patients (33 percent). Increased SFD confirmed denervation of the external anal sphincter in 12 patients (80 percent), being normal in 3 patients (20 percent). Distal RAER was abnormal in 13 patients (87 percent) and was normal in 2 patients (13 percent). In ten patients (67 percent), the three diagnostic modalities were in complete agreement, correctly identifying neuropathy in nine patients (60 percent) and excluding nerve damage in one patient (7 percent). Distal RAER was normal despite prolonged PNTML and increased SFD in one patient (7 percent). In two patients (13 percent), distal RAER was abnormal or absent despite normal PNTML and SFD. Pudendal nerve terminal motor latency was normal in the presence of abnormal distal RAER and increased SFD on electromyography in two patients (13 percent). CONCLUSIONS: Abnormal distal RAER compares favorably with current neurophysiologic tests used to diagnose pudendal neuropathy.

PURPOSE: This study relates our experience with local surgical management of perianal Crohn's disease. METHOD: Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention. RESULTS: All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus. CONCLUSION: Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.

BACKGROUND: Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP). METHODS: Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993. RESULTS: The two groups, 90 patients who underwent OBP and 98 patient who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7 vs. 9 days; P < 0.0001; chi-squared analysis), whereas the complication rate was similar (19 percent in the OBP group vs. 18 percent in the IBP group), including infectious complications (10 percent in the OBP group vs. 7 percent in the IBP group). Although operating time was similar (mean, 199 vs. 213 minutes) and estimated blood loss (mean, 528 vs. 536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300 vs. 3700 ml; P < 0.05; Student's t-test), intraoperative colloid administration (48 vs. 29 percent; P < 0.0002; chi-squared), 24-hour postoperative fluids (3224 vs. 2700 ml; P < 0.0001; Student's t-test), and postoperative fluid challenges (50 vs. 20 percent; P

PURPOSE: Abnormalities of rectoanal inhibitory or excitatory reflex in patients with fecal incontinence are well described. A spectrum of abnormal responses, other than those already described in the literature, has been observed in some patients with fecal incontinence and forms the subject of this report. METHOD: Forty-three patients with idiopathic or traumatic fecal incontinence were studied to evaluate their reflex responses to balloon distention of the rectum, and results were compared with reflex responses of 29 control subjects with no anorectal complaints. RESULTS: Control subjects revealed normal reflex responses consisting of initial excitation followed by inhibition in the proximal anal canal and an excitatory response in the distal anal canal. Patients who were incontinent revealed five different types of reflex patterns. Eleven patients (25.5 percent) with segmental sphincter defects from obstetric injuries exhibited no distal excitation but had normal response in the proximal anal canal (Group 1). Eleven patients (25.5 percent) with idiopathic incontinence exhibited normal proximal response but an inhibitory as opposed to excitatory response in the distal anal canal (Group 2). Three patients (7 percent) with iatrogenic trauma failed to register an excitatory response in the proximal or distal anal canal but revealed a normal inhibitory reflex (Group 3). Nine patients (21 percent) with idiopathic incontinence revealed excitatory response in the entire anal canal but no inhibition (Group 4). Nine patients (21 percent) with idiopathic incontinence had a normal reflex pattern (Group 5). CONCLUSION: Excitatory and inhibitory components of rectoanal reflexes may selectively be abolished in neurogenic or traumatic insults to visceral and somatic anal sphincters, resulting in altered rectoanal reflex patterns.

PURPOSE: Latency values of rectoanal reflexes may be altered in disorders of the pelvic floor. Evaluation of this relatively uninvestigated aspect of rectoanal reflexes may have diagnostic implications in patients with disorders of defecation. METHODS: We studied the latency of rectoanal inhibitory and excitatory reflexes to sequential balloon distention of the rectum with 60 ml and 120 ml of air in 14 normal controls (mean age, 41.5 (range, 19–66) years), in 14 patients with fecal incontinence (FI) (mean age, 44.2 (range, 28–72) years), and in 14 patients with slow transit constipation (STC) (mean age, 40.6 (range, 22–68) years). RESULTS: The mean latency of inhibition (FI=5.3 seconds; STC=4.6 seconds; controls=5.1 seconds) was remarkably similar for the three groups (P=0.19). The mean latency of excitation in the proximal anal canal (FI=2.8 seconds; STC =2.5 seconds; controls=2.8 seconds) was comparable in the three groups (P=0.58). The mean latency of excitation in the distal anal canal (FI=4.8 seconds; STC=2.6 seconds; controls=2.7 seconds) was prolonged in patients who were incontinent compared with the other two groups (P

PURPOSE: Our aim was to determine manometric status and functional outcome of the ileoanal pouch procedure in a subset of patients with defunctionalized anal sphincters as a result of long-term fecal diversion. METHODS: The anal manometric profiles of 12 patients defunctionalized for one year or more were compared with 26 patients with nondefunctionalized anal sphincters. Functional data were obtained from the Lahey Clinic Ileoanal Pouch Registry. RESULTS: Preoperative manometric data revealed a mean resting pressure of 91.5 mmHg in the nondefunctionalized group vs.68.7 mmHg in the defunctionalized group; mean squeezing pressure was 171.7 mmHg (nondefunctionalized group)vs.102.3 mmHg (defunctionalized group); and squeezing pressure volume was 1,283,000 mmHg3 (nondefunctionalized group)vs.585,000 mmHg3 (defunctionalized group). Functionally both groups had a mean of 6.1 bowel movements in a 24-hour period and could defer defecation for a mean of 2 hours. Leakage occurred in 22 percent of the defunctionalized group and 17 percent of the nondefunctionalized group (P=0.35). CONCLUSION: Despite physiologic perturbations, the long-term, defunctionalized anal sphincter can adequately support a restorative procedure without regard to timing of pouch creation.

Since the incorporation of the American Board of Proctology, development and refinement of the process of board certification has been a critical part of the establishment and growth of the specialty of colon and rectal surgery. Continued commitment to the process begun by the early pioneers of this field provides quality practitioners not only when initially trained, but increasingly throughout the continuum of each diplomate's professional career. Board certification and maintenance of certification are the most tangible examples of our commitment to our patients and the public.

BACKGROUND: Process and outcome measures for quality assessment of colorectal surgical care are poorly defined. OBJECTIVE: The aim of this study was to develop candidate end points for use in surgeon-specific registries designed for case reporting and quality improvement program development. DESIGN: The study design was based on modified Delphibased development of consensus quality end points. SETTING: This study was undertaken by the American Society of Colon and Rectal Surgeons Executive Council, Quality Committee, and by the ColoRectal Education System Template Committee, American Board of Colon and Rectal Surgery. PATIENTS: No patients were included in this study. INTERVENTIONS: Six areas of colorectal surgery were defined by members of the American Society of Colon and Rectal Surgeons' Executive Council and the American Board of Colon and Rectal Surgery to cover areas of importance for colorectal surgeons. These included colectomy, rectal cancer, hemorrhoidectomy, anal fistula and abscess, colonoscopy, and rectal prolapse. Relevant American Society of Colon and Rectal Surgeons' committee members through a series of 4 panel discussions identified important demographic, process, and outcome measures in each of these 6 areas that might be suitable for the American College of Surgeons case log. Panel size was sequentially expanded from 8 members to 28 members to include all active committee members. Panelists contributed additional process and outcome measures for inclusion during each discussion. Modified Delphi methodology was used to generate consensus, and, after each panel discussion, members rated the relative importance of each end point from 1 (least important) to 4 (most important). MAIN OUTCOME MEASURES: The mean rating for each process and outcome measure after each round was recorded with the use of standardized definitions for relevant variables. RESULTS: Eighty-nine process and outcome measures were compiled and rated. Mean scores following the final round ranged from a low of 1.3 (anal fistula/abscess, preoperative imaging) to a high of 4.0 (colectomyanastomotic leak). LIMITATIONS: The limitations of this study involved the use of consensus, small study size, and the fact that no end points were excluded. CONCLUSIONS: With the use of modified Delphi methodology, a consensus-derived ranked list of 89 process and outcome measures was developed in 6 key areas of colorectal surgery. These data provide a framework for development of guideline standards for case-reporting program development initiatives for colon and rectal surgery.

BACKGROUND: Successful biofeedback therapy has been reported in the treatment of fecal incontinence and constipation. It is uncertain which groups of incontinent patients benefit from biofeedback, and our impression has been that biofeedback is more successful for incontinence than for constipation. PURPOSE: This study was designed to review the results of biofeedback therapy at the Lahey Clinic. METHODS: Biofeedback was performed using an eightchannel, water-perfused manometry system. Patients saw anal canal pressures as a color bar graph on a computer screen. Assessment after biofeedback was by manometry and by telephone interview with an independent researcher. RESULTS: Fifteen patients (13 women and 2 men) with incontinence underwent a mean of three (range, 1–7) biofeedback sessions. The cause was obstetric (four patients), postsurgical (five patients), and idiopathic (six patients). Complete resolution of symptoms was reported in four patients, considerable improvement in four patients, and some improvement in three patients. Manometry showed a mean increase of 15.3 (range, −3–30) mmHg in resting pressure and 35.7 (range, 13–57) mmHg in squeezing pressure after biofeedback. A successful outcome could not be predicted on the basis of cause, severity of incontinence, or initial manometry. Twelve patients (10 women and 2 men) with constipation underwent a mean of three (range, 1–14) biofeedback sessions. Each had manometric evidence of paradoxic nonrelaxing external sphincter or puborectalis muscle confirmed by defography or electromyography. All patients could be taught to relax their sphincter in response to bearing down. Despite this, only one patient reported resolution of symptoms, three patients had reduced straining, and three patients had some gain in insight. CONCLUSIONS: Biofeedback helped 73 percent of patients with fecal incontinence, and its use should be considered regardless of the cause or severity of incontinence or of results on initial manometry. In contrast, biofeedback directed at correcting paradoxic external sphincter contraction has been disappointing.

Cholangiocarcinoma is an infrequent complication of inflammatory bowel disease. Although increasing numbers of cholangiocarcinomas are being reported in association with ulcerative colitis, the occurrence of this disease in patients with Crohn's disease is rare. To understand this complication better, we have reported the case of a patient with Crohn's disease in whom cholangiocarcinoma subsequently developed and reviewed the literature.

PPURPOSE: The physiologic changes that occur when the small bowel is used as a reservoir, as in the ileal pouchanal anastomosis, are poorly understood. Alterations in bowel permeability, which may lead to bacterial translocation that could result in illness or dysfunction of the pouch, may be one such consequence of the pouch procedure. METHODS: Whole-bowel permeability was evaluated in patients with and without the pouch through the use of an orally consumed nonmetabolizable sugar clearance technique. Patients in whom the ileal pouchanal anastomosis was performed for ulcerative colitis (17 patients) and patients with familial polyposis (7 patients) were compared with normal healthy volunteers (10 patients) and patients with ulcerative colitis with and without curative colectomy and ileostomy (6 and 5 patients, respectively). RESULTS: Measured by this technique, no differences were noted in bowel permeability between the volunteers and patients with ulcerative colitis, even after colectomy and ileostomy (1.7±0.4 in normal healthy volunteers, 1.8±0.5 in patients with ulcerative colitis without stoma, and 1.4±0.2 in patients with ulcerative colitis with ileostomy). The group of patients with an ileal reservoir, however, had a significantly increased index of measured bowel permeability (3.5±0.5 in patients with ulcerative colitis and 5.1±0.7 in patients with familial polyposis;P

Background: To control the increased risk of colorectal carcinoma in patients with long-standing ulcerative colitis, surveillance colonoscopy is widely recommended. Methods: To assess the role of colonoscopic surveillance in affecting colorectal carcinoma-related mortality, an outcome analysis was performed. Results: Among the total of 41 patients who developed carcinoma associated with ulcerative colitis, 19 patients were under colonoscopic surveillance and 22 patients were not. Carcinoma was detected at a significantly earlier Dukes' stage in the surveillance group ( P = 0.039). Four patients in the surveillance group died, compared with 11 patients in the no-surveillance group. The 5-year survival rate was 77.2% for the surveillance group and 36.3% for the no-surveillance group ( P = 0.026). Conclusions: These results suggest that colonoscopic surveillance reduces colorectal carcinoma-related mortality by allowing the detection of carcinoma at an earlier Dukes' stage.

We sought to identify variability in surgical care for rectal cancer across the United States. In particular, we hypothesized that in large areas of the country patients are infrequently treated by proctectomy using restorative ("sphincter-sparing") techniques.We used all-payer state hospital discharge data from 21 states to determine county level rates of restorative proctectomy vs nonrestorative proctectomy (with colostomy) for rectal cancer. County of residence data were then used to graphically represent variability in surgical care for rectal cancer.From January 2002 through December 2004, 19,912 proctectomies were performed for rectal cancer. Overall, restorative techniques were used in 50.1% of all patients, whereas nonrestorative techniques were used in 49.9%. In approximately one-fourth of the counties surveyed (n = 125; 26%) nonrestorative techniques were used in greater than 60% of proctectomy cases. In the majority of counties (n = 266; 54%,) nonrestorative techniques were used in 41% to 60% of proctectomy cases. Only 20.0% (n = 98) of counties were characterized by rates of nonrestorative proctectomy below 41%. The extremal quotient was 16.9, indicating significant county variability in colostomy formation for rectal cancer surgery.There is significant geographic variability in the rates of restorative vs nonrestorative proctectomy for rectal cancer in the United States. Large areas of the country report particularly high rates of colostomy formation after proctectomy. An in-depth population-based analysis designed to identify factors contributing to this variability in surgical treatment of rectal cancer is needed.