A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn's disease.

OBJECTIVE: To evaluate 2- and 12-month outcomes after ligation of the intersphincteric fistula tract (LIFT) in Crohn's disease (CD). BACKGROUND: Surgical approaches to perianal fistulas in CD are frequently ineffective and hampered by concerns over adequate wound healing and sphincter injury. The efficacy of LIFT in CD patients is unknown. METHODS: Consecutive cases of CD patients with transsphincteric fistulas were prospectively analyzed. Fistula healing and 2 validated quality-of-life indices were assessed. RESULTS: Fifteen CD patients (9 women; mean age = 34.8 years) were identified. Location of the fistula was lateral (n = 10; 67%) or midline (n = 5; 33%). LIFT site healing was seen in 9 patients (60%) at 2-month follow-up. No patient developed fecal incontinence. LIFT site healing was seen in 8 of the 12 patients (67%) with complete 12-month follow-up. Significant factors for long-term LIFT site healing were lateral versus midline location (P = 0.02) and longer mean fistula length (P = 0.02). Patients who had successful operations significantly improved both their mean Wexner Perianal Crohn's Disease Activity Index and McMaster Perianal Crohn's Disease Activity Index quality-of-life scores at 2-month follow-up (14.0-3.8, P = 0.001, and 10.4-1.8, P = 0.0001, respectively). CONCLUSIONS: CD-associated anal fistulas may be treated with LIFT. This surgical procedure is a safe, outpatient procedure that minimizes both perianal wound creation and sphincter injury.

Predictors of mortality after colectomy for fulminant Clostridium difficile colitis.

OBJECTIVES: To present, to our knowledge, the largest experience with colectomy for fulminant Clostridium difficile colitis and to propose factors significant in predicting mortality. DESIGN: Retrospective medical record review. SETTING: University teaching hospital. PATIENTS: Seventy-three patients undergoing colectomy between 1994 and 2005 for C difficile-associated pseudomembranous colitis. MAIN OUTCOME MEASURES: Preoperative predictors of in-hospital mortality. RESULTS: Seventy-three of 5718 cases (1.3%) of C difficile colitis required colectomy. Mean age was 68 years. In-hospital mortality was 34% (n = 25). Eighty-six percent (n = 63) of patients received a subtotal colectomy. Patients presented with diarrhea (84%; n = 61), abdominal pain (75%; n = 55), and ileus (16%; n = 12). Mean duration of symptoms was 7 days followed by 4 days of medical treatment prior to colectomy. On univariate analysis, an admitting diagnosis other than C difficile (P = .049), vasopressor requirement (P = .001), intubation (P = .001), and mental status changes (P < .001) were significant predictors of mortality. Arterial lactate level (4.9 vs 2.4 mmol/L; P = .007) was significantly higher and length of medical management (6.4 vs 3.0 days; P = .006) was significantly longer in the mortality group. Platelet counts (169 x 10(3)/microL vs 261 x 10(3)/microL [to convert to x 10(9)/L, multiply by 1]; P = .04) were significantly lower in the mortality group. On multivariate analysis, vasopressor requirement (P = .04; odds ratio, 5.0), mental status changes (P = .002; odds ratio, 12.6), and treatment length (P = .002; odds ratio, 1.4) remained significant predictors of mortality. CONCLUSIONS: Colectomy for C difficile colitis carries a substantial mortality regardless of patient age and white blood cell count. Preoperative vasopressor requirement, mental status changes, and length of medical treatment significantly predict mortality.

Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.

BACKGROUND: Atrial fibrillation (AF) is a common complication after major noncardiac thoracic surgery and increases the cost and morbidity of these operations. We sought to derive and validate a clinical prediction rule to risk-stratify patients for postoperative AF. METHODS: For a cohort of cancer patients who underwent noncardiac thoracic surgery, we examined the association of preoperative clinical variables with development of postoperative AF. Logistic regression identified multivariable predictors of AF and a clinical risk score was developed by assigning weighted point scores for the presence of each significant covariate. An independent data set was used for validation purposes. RESULTS: Of the 856 patients, 147 (17.2%) developed postoperative AF. Male gender (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1 to 2.4), advanced age (55 to 74 years OR 4.4, 95% CI 2.0 to 9.8; > or =75 years OR 9.2, 95% CI 3.9 to 21.5), and preoperative heart rate greater than or equal to 72 beats per minute (OR 1.7, 95% CI 1.2 to 2.5) were independent predictors of postoperative AF. A risk score was assigned with male gender and heart rate greater than or equal to 72 beats per minute each receiving 1 point, and age 55 to 74 and greater than or equal to 75 years receiving 3 and 4 points, respectively. The risk of postoperative AF ranged from 0% (0 points) to 54.6% (6 points) (p < 0.001). The score-based risk in both derivation and validation sets was similar (p = 0.66). CONCLUSIONS: A prediction rule using clinical variables can be used to predict the risk of postoperative AF after noncardiac thoracic surgery. This information can be used to guide prophylactic therapy.