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

AIM: The advent of rescue medical therapy (cyclosporin or infliximab) and laparoscopic surgery has shifted the paradigm in managing steroid refractory acute severe ulcerative colitis (ASUC). We investigated prospectively the impact of rescue therapy on timing and postoperative complications of urgent colectomy and subsequent restorative surgery for steroid refractory ASUC. METHOD: All consecutive presentations of steroid refractory ASUC at the Royal Brisbane Hospital (1996-2009) were entered in the study. Data collated included demographics, clinical and laboratory parameters on admission, medical therapy and operative and postoperative details. Steroid refractory ASUC patients undergoing immediate colectomy were compared with those failing rescue therapy and requiring same admission colectomy. RESULTS: Of 108 steroid refractory ASUC presentations, 19 (18%) received intravenous steroids only and proceeded directly to colectomy. Rescue medical therapy was instituted in 89 (82%) patients with 30 (34%) failing to respond and proceeding to colectomy. There was no significant difference in the median time from admission to colectomy for rescue therapy compared with steroid-only cases (12 vs 10 days, P = 0.70) or 30-day complication rates (27%vs 47%, P = 0.22). The interval from colectomy to a subsequent restorative procedure was significantly longer for patients who failed rescue therapy (12 vs 5 months, P = 0.02). Furthermore 30-day complications following pouch surgery were significantly higher in patients who failed rescue therapy (32%vs 0%, P = 0.01). CONCLUSION: Rescue therapy in steroid refractory ASUC is not related to delay in urgent colectomy or increased post-colectomy complications.

The ideal ileal-pouch design: a long-term randomized control trial of J- vs W-pouch construction.

BACKGROUND: The IPAA has become established as the preferred technique for restoring intestinal continuity postproctocolectomy. The ideal pouch design has not been established. W-pouches may give better functional results owing to increased volume, whereas the J-pouch's advantage is its straightforward construction. We report short- and long-term results of an randomized control trial designed to establish the ideal pouch. DESIGN: Ninety-four patients were randomly assigned to J- and W-pouches (49:45) and assessed at 1 and 8.7 years postoperatively. Assessment was questionnaire based and designed to assess pouch function and patient quality of life. RESULTS: Eighty-five percent of patients were followed up at 1 year, and 68% were followed up at 8.7 years. At 1 year, there was a significant difference in 24-hour bowel movement frequency J- vs W-pouches 7 vs 5(p < 0.001) and in daytime frequency J- vs W-pouches 6 vs 4 (p < 0.001), with no difference in nocturnal function. At 9-year follow-up, function had equilibrated between the 2 groups: 24-hour bowel movement frequency J- vs W-pouches 6.5 vs 6 (p = 0.36), daytime frequency 5.5 vs 5 (p = 0.233), and nocturnal function 1 vs 1 (p = 0.987). Mean operating time of J- and W-pouches was 195 and 215 minutes (p < 0.05). All other parameters, pad usage, urgency, incontinence, and quality of life, did not differ significantly between groups. CONCLUSION: These data demonstrate that the theoretical functional advantage conferred on the W-pouch by its greater volume exists only in the short term and is of little consequence to patients' long-term quality of life. This advantage is attenuated as the pouches mature, resulting in no disparity in pouch function. This, combined with the more consistent, efficient, and easily taught construction of the J-pouch, should conclusively establish it as the optimum ileal-pouch design.

Laparoscopic resection of advanced colorectal cancer.

BACKGROUND: Palliative resection of the primary tumour in asymptomatic patients with stage IV colorectal cancer is associated with improved survival and fewer complications. Laparoscopic surgery is widely employed in the curative treatment of colorectal cancer, but its value in advanced colorectal cancer remains unclear. METHODS: All patients who underwent laparoscopic resection of primary colorectal cancer in this unit between June 1991 and Jan 2010 were entered into a prospective computerized database. Outcomes for patients with laparoscopic resection of stage IV colorectal cancer were compared with those of patients who had laparoscopic surgery for stage I disease. RESULTS: Some 185 patients with stage IV colorectal cancer who underwent laparoscopic resection were compared with 310 patients who had stage I colorectal cancer. Some 94·1 and 98·4 per cent of operations respectively were completed laparoscopically. Hospital stay was slightly longer in the group with stage IV disease (mean 6·2 versus 5·3 days; P = 0·091). The 30-day mortality rate was 2·7 per cent in patients with stage IV disease and 0·6 per cent in those with stage I tumours (P = 0·061). There was no difference in complications. One-year survival rates were 77·8 and 99·0 per cent respectively (P < 0·001). CONCLUSION: Short-term outcomes after laparoscopic surgery for stage IV colorectal cancer in selected patients are equivalent to those for stage I cancers.

Optimal port site placement.

Port (trocar) positioning is an important component of the successful completion of laparoscopic colorectal surgery. Although individual surgeons will vary the positions, the principles are well established. The type and positioning of ports will continue to evolve as technology advances.

Preservation of sexual and bladder function after laparoscopic rectal surgery.

BACKGROUND: There have recently been reports of higher levels of bladder and sexual dysfunction in men after laparoscopic rectal surgery when compared with those undergoing open surgery. This has led some surgeons to question the role of the laparoscopic approach to rectal surgery. METHOD: This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2406 patients undergoing laparoscopic colorectal surgery. Bladder function, potency and ejaculation were assessed at postoperative clinic visits for men undergoing laparoscopic low or ultra-low anterior resection and abdominoperineal excision of the rectum. RESULTS: A total of 101 males were identified (median age 62 years: range 20-90 years). Urinary dysfunction was reported by six (6%) patients. Six (6%) patients had sexual dysfunction, manifesting as retrograde ejaculation in four patients and erectile dysfunction in a further two patients. CONCLUSIONS: The low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced, dedicated laparoscopic colorectal surgeons. Laparoscopic restorative surgery for rectal cancer has been performed here only since 2001 after considerable experience accrued in operating on benign rectal disease and colon cancer. Studies from elsewhere reporting poorer functional outcomes have probably included a significant number of patients on the surgeons''learning curve'.

Ileal pouch-anal anastomosis: the Australasian experience.

OBJECTIVE: The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia. METHOD: The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results. RESULTS: Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005). CONCLUSION: A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.

Features of colorectal cancers with high-level microsatellite instability occurring in familial and sporadic settings: parallel pathways of tumorigenesis.

High-level microsatellite instability (MSI-H) is demonstrated in 10 to 15% of sporadic colorectal cancers and in most cancers presenting in the inherited condition hereditary nonpolyposis colorectal cancer (HNPCC). Distinction between these categories of MSI-H cancer is of clinical importance and the aim of this study was to assess clinical, pathological, and molecular features that might be discriminatory. One hundred and twelve MSI-H colorectal cancers from families fulfilling the Bethesda criteria were compared with 57 sporadic MSI-H colorectal cancers. HNPCC cancers presented at a lower age (P < 0.001) with no sporadic MSI-H cancer being diagnosed before the age of 57 years. MSI was less extensive in HNPCC cancers with 72% microsatellite markers showing band shifts compared with 87% in sporadic tumors (P < 0.001). Absent immunostaining for hMSH2 was only found in HNPCC tumors. Methylation of hMLH1 was observed in 87% of sporadic cancers but also in 55% of HNPCC tumors that showed loss of expression of hMLH1 (P = 0.02). HNPCC cancers were more frequently characterized by aberrant beta-catenin immunostaining as evidenced by nuclear positivity (P < 0.001). Aberrant p53 immunostaining was infrequent in both groups. There were no differences with respect to 5q loss of heterozygosity or codon 12 K-ras mutation, which were infrequent in both groups. Sporadic MSI-H cancers were more frequently heterogeneous (P < 0.001), poorly differentiated (P = 0.02), mucinous (P = 0.02), and proximally located (P = 0.04) than HNPCC tumors. In sporadic MSI-H cancers, contiguous adenomas were likely to be serrated whereas traditional adenomas were dominant in HNPCC. Lymphocytic infiltration was more pronounced in HNPCC but the results did not reach statistical significance. Overall, HNPCC cancers were more like common colorectal cancer in terms of morphology and expression of beta-catenin whereas sporadic MSI-H cancers displayed features consistent with a different morphogenesis. No individual feature was discriminatory for all HNPCC cancers. However, a model based on four features was able to classify 94.5% of tumors as sporadic or HNPCC. The finding of multiple differences between sporadic and familial MSI-H colorectal cancer with respect to both genotype and phenotype is consistent with tumorigenesis through parallel evolutionary pathways and emphasizes the importance of studying the two groups separately.

Hypothermia in open and laparoscopic colorectal surgery.

PURPOSE: Perioperative hypothermia has been shown to be an important determinant of outcome after open colorectal resections. The degree of hypothermia occurring with laparoscopic-assisted colorectal surgery is, however, unknown, and the effectiveness of standard warming measures is untested. This study was designed to assess hypothermia in open and laparoscopic-assisted colonic resections using a standardized warming protocol. METHODS: A prospective, nonrandomized study was performed with temperature measurements recorded every ten minutes. Statistical analysis was based on repeated measures analysis of variance models with significance set at the conventional 95 percent (two tailed). RESULTS: A total of 107 patients were entered into the trial; 68 had open and 39 had laparoscopic colectomies. The groups were well matched for age, weight, and duration of surgery, with a median operating time of 180 minutes in each group. The average drop in temperature from commencement of surgery to lowest point was 0.68 degrees C (standard deviation, 0.08) in the open group, compared with 0.53 degrees C (standard deviation, 0.06) in the laparoscopic group (P = 0.126). CONCLUSIONS: Laparoscopic-assisted colorectal surgery is not associated with a higher incidence of perioperative hypothermia than open colorectal surgery using a standard warming regimen for both groups. On the basis of these results, standard temperature conservation is adequate, even for long, complex laparoscopic procedures.

Laparoscopically assisted colorectal surgery in the elderly.

INTRODUCTION: Open colorectal surgery in elderly patients is associated with increased morbidity and mortality rates compared with those in younger age groups. It also requires more intensive postoperative support, longer hospitalization, and in many cases leads to prolonged rehabilitation or institutionalization. Because of its less invasive nature, laparoscopically assisted colorectal surgery may lead to a reduced period of convalescence. However, the safety of advanced laparoscopic surgical techniques in the elderly has not been established, so this prospective comparative study was undertaken. METHODS: All patients aged 80 years or more who were undergoing an elective laparoscopic or open colorectal procedure between 1 January 1992 and 30 June 1997 were assessed prospectively. Patients having simple stoma formation were excluded. Perioperative care, operative results and subsequent function were analysed. RESULTS: There were 42 patients in the laparoscopic group and 35 in the open group, with a median age of 84 years in each group. Five patients undergoing laparoscopic surgery required conversion to an open procedure. No complications related to laparoscopy occurred. Three patients died after operation in the laparoscopic group and four in the open group, with morbidity in seven and 15 patients respectively. Median hospital stay was 9 (range 4-21) days for patients having the laparoscopic operation, and 17 (range 7-28) days in the open cases. At 4 weeks after operation 30 of the 35 independent patients surviving the operation in the laparoscopic group and 16 of 28 in the open group were back to preoperative activity levels. CONCLUSION: In this series laparoscopically assisted colorectal surgery was safe and was associated with a low incidence of complications, short hospitalization and a rapid return to preoperative activity levels when compared with open colorectal resections in this age group.

Marsupialization of presacral collections with use of an endoscopic stapler.

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

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

PURPOSE: The objectives of this study were to refine the technique of laparoscopically assisted anterior resection (LAR) for diverticular disease and to analyze the morbidity and mortality rates, and longer term follow-up of the first 100 consecutive patients. METHODS: Data were collected prospectively, and follow-up was performed by an independent assessor using a standardized questionnaire. RESULTS: The median duration of surgery was 180 minutes, the median time for passage of flatus was 2 days after surgery, and the median length of hospital stay was 4 days. Overall, the morbidity rate was 21%, and the wound infection rate was 5%. There were no deaths. Eight patients underwent open laparotomy. The rate of complications was significantly greater in the latter group of patients (75%) than in those who underwent laparoscopy (16%, p = 0.002). The comparison between the first 20 cases and the last 20 patients revealed a significantly shorter duration of surgery (median 225 min. vs. 150 min.; p < 0.0001) and decreased length of stay (6 days vs. 4 days, p < 0.0001). Apart from a nonsignificant increase in the length of surgery, there were no differences in other study parameters when comparisons were made between those patients who underwent LAR for complicated diverticular disease and those patients who underwent uncomplicated diverticular disease. FOLLOW-UP: Ninety patients were available for follow-up at a median time of 37 months. Ninety-three percent of the patients reported that the surgery had improved their symptoms. No patient required hospitalization, and no one was treated with antibiotics for recurrent symptoms. CONCLUSION: Laparoscopically assisted anterior resection for diverticular disease has acceptable morbidity and mortality rates and a median postoperative hospital stay of only 4 days. Follow-up investigations revealed no recurrence of diverticulitis, and patients reported satisfaction regarding cosmetic and functional results.

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

PURPOSE: Objectives of this study were to describe the technique of laparoscopic-assisted resection rectopexy and audit the clinical outcomes, including review of functional results. METHODS: Data were prospectively collected for duration of operation, time to passage of flatus and feces postoperatively, hospital stay, morbidity, and mortality. Follow-up was performed by an independent assessor using a standardized questionnaire. Patients were also assessed by clinical review or telephone interview. RESULTS: During a four-year period, 34 patients underwent laparoscopic repair for rectal prolapse, of which 30 patients underwent laparoscopic-assisted resection rectopexy. Median duration of the operations was 185 minutes, median time for passage of flatus was two days postoperatively, and median length of hospital stay was five days. Morbidity was 13 percent and mortality rate was 3 percent. Comparison between the first ten patients who underwent laparoscopic-assisted resection rectopexy and the last ten revealed a significant reduction in both median duration of operating time (224 vs. 163 minutes; P < 0.005) and length of stay (6 vs. 4 days; P < 0.015). Follow-up study conducted at a median time of 18 months revealed that most patients (92 percent) felt that the operation had improved their symptoms, that incontinence was improved in 14 of 20 patients with impaired continence (70 percent), and that constipation was improved in 64 percent. Symptoms of incomplete emptying and the need to strain at stool were both improved in 62 and 59 percent of patients, respectively. No full-thickness recurrences have occurred, but two patients have had mucosal prolapse detected (7 percent) and treated. CONCLUSION: Laparoscopic-assisted resection rectopexy is feasible and safe, with acceptable recurrence rates and functional results compared with the open procedure in the surgical literature. There is rapid return of intestinal function associated with an early discharge from hospital.

Laparoscopic stoma formation for faecal diversion.

BACKGROUND: Laparoscopic creation of an intestinal stoma may be preferable to open operation when intervention is required solely for faecal diversion. METHODS: Experience with laparoscopic intestinal stoma formation for faecal diversion from a single institution is presented. RESULTS: A total of 55 stomas were studied, 40 laparoscopic and 15 open. The conversion rate from laparoscopic to open operation was 5 per cent. Mean(s.e.m.) operating time was significantly reduced for laparoscopic stomas (54(4.7) versus 72(8.7) min). Time to return of bowel function was significantly reduced (1.6(0.3) versus 2.2(0.2) days). Mean(s.e.m.) hospital stay was significantly reduced in the laparoscopic group (7.4(0.5) versus 12.6(2.5) days). CONCLUSION: Morbidity and mortality appeared to be reduced in patients undergoing laparoscopic stoma formation. The technique was found to be safe, suitable for the majority of patients and to give results superior to those of open surgery.

Laparoscopic colectomy.

BACKGROUND: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. METHODS: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. RESULTS: There were 359 cases (206 females, 153 male) average age 58.8 years (18-94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience-the last 20 cases of anterior resection took 150 min (110-240) and of RHC took 130 min (65-210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5-7 days (2-33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days-sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15-46 months). CONCLUSIONS: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer.

Large intestinal lymphocytic phlebitis and venulitis in chronic ulcerative colitis.

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

Laparoscopic colorectal surgery--new advances and techniques.

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

A long-term follow-up of patients undergoing colectomy for chronic idiopathic constipation.

BACKGROUND: Chronic idiopathic constipation is a condition that mainly affects young women and is commonly associated with symptoms of abdominal pain and bloating. It has been proposed that patients with severe symptoms who are unresponsive to conservative measures can be managed by colonic resection. The aim of the present study was to assess the long-term outcome of such surgery on patients with a diagnosis of chronic idiopathic constipation. METHODS: Ninety-six patients (92 females, 4 males) underwent either a total colectomy and ileorectal anastomosis (n = 86) or subtotal colectomy and caecorectal anastomosis (n = 10) between 1986 and 1994. RESULTS: Postoperative mortality was 2.1%, 3.1% suffered from an anastomotic leak and 11.5% developed a pelvic abscess. Follow up was completed in 92.7% of patients at a mean of 5.0 +/- 2.3 years. Following surgery, symptomatic improvement was reported by 81.6% of patients. However, 51.2% still experienced difficulty with straining, 50.6% had some degree of anal incontinence, 55.2% continued to experience abdominal pains and 75.9% continued to be troubled by abdominal bloating. Reoperation was performed on 35.6% of patients (mainly for division of adhesions), and 9.2% of patients required an ileostomy. CONCLUSIONS: Colectomy is associated with relief of constipation in a majority of patients with chronic idiopathic constipation. However, it is associated with a considerable morbidity and is less effective in resolving symptoms of abdominal pain and bloating.