Prophylactic ureteric catheters in laparoscopic colorectal surgery.

BACKGROUND: The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure. METHODS: Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed. RESULTS: Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group. CONCLUSION: Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Do elderly patients benefit from laparoscopic colorectal surgery?

BACKGROUND: The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients. AIM: To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP). METHODS: A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age >or= 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality. RESULTS: 641 patients (M/F - 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) - p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3-17) days versus 8.7 (4-22) days in group B (p <0.0001), and LAP: 5.3 (2-19) days versus 6.4 (2-34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003). CONCLUSIONS: Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness.

BACKGROUND: Numerous studies have demonstrated the feasibility of laparoscopy in the management of acute adhesive small-bowel obstruction (AASBO). However, comparative data with laparotomy are lacking. The aim of this study was to compare laparoscopy and laparotomy for the treatment of AASBO in terms of patient outcome and cost-effectiveness. METHODS: A retrospective chart review of all patients who underwent surgery for AASBO from 1999 to 2005 was conducted. Data recorded included operative and postoperative course, among others. Operative and total hospital charges were estimated from the Patient Accounting System. RESULTS: Thirty-one patients who underwent laparoscopy were matched to a similar group of patients who underwent laparotomy. In the laparoscopy group, four patients (13%) had a laparoscopy-assisted procedure and ten patients (32%) were converted. The laparoscopy group was subdivided into laparoscopy, laparoscopy-assisted, converted, and assisted-converted subgroups. In the majority of the patients, AASBO was secondary to a single band. Overall morbidity was significantly higher in the laparotomy group (p = 0.007). Morbidity rates were statistically significant between the laparoscopy and assisted-converted subgroups (p = 0.0001) but not between the laparotomy group and assisted-converted subgroup (p = 0.19). Median hospital stay and median time to first bowel movement were significantly shorter in the laparoscopy group. Charge data were available for only the last three years of the study. Operative charges and total hospital charges were similar between the laparoscopy and the laparotomy groups (p = 0.14 and p = 0.10, respectively). There was a significant difference in total hospital charges between the laparoscopy subgroup and laparotomy group (p = 0.03). CONCLUSIONS: Laparoscopy for AASBO is associated with reduced hospital stay, early recovery, and decreased morbidity. Laparoscopy-assisted and converted surgeries do not differ significantly from laparotomy in regard to patient outcome. Operative and total hospital charges are similar for both laparoscopy and laparotomy.

Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons.

BACKGROUND: The postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States. METHODS: A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC. RESULTS: Only 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice. CONCLUSIONS: Surveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

BACKGROUND: Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. METHODS: The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure. RESULTS: A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. CONCLUSION: A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease.

BACKGROUND: There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD). METHODS: A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: 7 months. RESULTS: From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians.

OBJECTIVE: Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA. METHODS: After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years. RESULTS: From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2). CONCLUSION: IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.

Quality of life after colectomy for colonic inertia.

BACKGROUND: Total abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long-term health related quality of life in these patients in relation to their functional outcome. METHODS: A consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was health-related quality of life assessed at follow-up using the SF-36 Health Survey. RESULTS: A total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3+/-27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7+/-2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF-36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations. CONCLUSIONS: After TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

High compliance rates observed for follow up colonoscopy post polypectomy are achievable outside of clinical trials: efficacy of polypectomy is not reduced by low compliance for follow up.

INTRODUCTION: The National Polyp Study demonstrated that removal of adenomas with at least a three-year follow up reduced the incidence of colorectal cancer. However, compliance with follow up colonoscopy may affect the estimates of reduction in colorectal cancer incidence demonstrated by the National Polyp Study. While an 80% compliance rate for follow up colonoscopy was achieved during the National Polyp Study, the compliance rate for follow up colonoscopy is unknown in the general population. The aim of this study was to determine the compliance rate for follow up colonoscopy and factors which affect follow up. METHODS: A retrospective medical record review to identify patients who had adenomatous polyps excised in 1997 was undertaken. Patients who had inflammatory bowel disease, a prior history of colorectal cancer, familial adenomatous polyposis syndrome, colonic surgery; incomplete polypectomy or incomplete colonoscopy, and those patients who died before planned follow up, were excluded from analysis. Follow up was performed by telephone survey. RESULTS: Three hundred and thirty-three patients were identified (196 males; 147 females) with a mean age of 70 years. Three hundred and thirty-one (99%) of 333 had a documented recommendation for follow up of three years or less. Thirty-four percent (113 of 333) had previously undergone colonoscopy; 29% (98 of 333) had previously undergone polypectomy and 54% (180 of 333) were symptomatic at the time of the colonoscopy. Twenty-eight percent (40 of 141) had a family history of colorectal cancer. Pathology at polypectomy included a single polyp and polyps less than 10 mm in 68% and 88% of cases, respectively. Follow up was available in 211 of these cases, 179 (85%) of which had been compliant with follow up colonoscopy. In a univariate analysis, previous colonoscopy (P = 0.035), previous polyps (P = 0.043), asymptomatic status at time of colonoscopy (P = 0.021), polyp size (P = 0.008) and number of polyps (P = 0.010) were significantly associated with patients who were compliant with follow up colonoscopy. A multivariate logistics regression analysis revealed number of polyps (P = 0.036) and polyp size (P = 0.045) to be statistically significantly associated with compliance. CONCLUSION: Compliance with follow up colonoscopy after polypectomy is greater than 80%, regardless of age, education, family history, prior colonoscopy, or prior polypectomy. Risk reduction published in the National Polyp Study may likely reflect what can be achieved through the general use of colonoscopy for surveillance.

The effect of diverticular disease on the colonic J pouch.

OBJECTIVE: The aim of this study was to assess the impact of the diverticular disease (DD) on function and on postoperative complications of the colonic J-pouch (CJP) with pouch-anal anastomosis. METHODS: Patients who underwent a CJP between December 1990 and August 2001, were retrospectively reviewed. The presence of DD in the CJP was assessed on pouchogram prior to ileostomy closure. A questionnaire designed to evaluate the degree of continence (total incontinence score (IS): 0 = worst, 20 = best) and pouch evacuation (total evacuation score (ES): 0 = worst, 28 = best) was used for comparison between patients with DD and those without DD (NDD). RESULTS: Sixty-six patients (47 males; 19 females) with a median age of 68 years (range 28-87 years) were included. The median follow-up period was 22 months (range 2-106 months). Twenty-four patients comprised the DD group and 42 were in the NDD group. The two groups were comparable for age, gender and time from ileostomy closure; all patients with postoperative chemoradiation therapy were in the NDD group. The total ES and IS total did not significantly differ between the two groups with a P-value of 0.11 and 0.09 respectively. Furthermore, there was no significant difference in the total incidence of pouch complications between the two groups (3 strictures, 1 leak, 1 fistula in the NDD group vs. 1 pelvic sepsis in the DD group; P = 0.4). CONCLUSIONS: The presence of DD in a CJP does not seem to impact pouch function or the postoperative complication rate.

Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

INTRODUCTION: Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis. METHODS: All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed. RESULTS: Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients. CONCLUSION: Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.

Anal ultrasound and endosonographic measurement of perineal body thickness: a new evaluation for fecal incontinence in females.

BACKGROUND: Perineal body thickness (PBT) is measured by endoanal ultrasonography. The literature has shown that women with obstetric trauma to the anal sphincter have decreased PBT, and a measurement of 10 mm or less has been proposed as abnormal. Therefore, this study aimed to compare the proposed definitions of normal to pathologic findings in patients with fecal incontinence (FI) and to correlate PBT with anorectal physiologic findings. METHODS: All female patients who had endoanal ultrasonography and PBT measurement for evaluation of FI were assessed and divided into three groups on the basis of PBT: 10 mm or less, 10 to 12 mm, more than 12 mm. The degree of FI (0 = complete continence; 20 = complete incontinence) was correlated with PBT. RESULTS: For this study, 83 female patients with a mean age of 59.7 years (range, 30-88 years) had endoanal ultrasonography and PBT measurement. Sphincter defects were suggested by endoanal ultrasonography in 77% of the patients in the three groups as follows: 57 (97%) of 59 patients, 4 (36%) of 11 patients, and 3 (23%) of 13 patients. The mean external sphincter defect angle was 110 degrees (range, 45-170 degrees ), and the mean FI score was 13.8. For 89% of the patients there was a history of vaginal delivery. As reported, 35% had undergone one or more prior perineal surgeries, 27% had both, and 4% denied having had either. A significant correlation between sphincter defect and PBT (p < 0.001) was noted. External sphincter defect angles were negatively correlated with PBT (p = 0.001). CONCLUSION: A PBT of 10 mm or less is considered abnormal, whereas a PBT of 10 mm to 12 mm is associated with sphincter defect in one-third of patients with FI. Those with a PBT of 12 mm or more are unlikely to harbor a defect unless they previously have undergone reconstructive perineal surgery.

Can the procedure for prolapsing hemorrhoids (PPH) be done twice? Results of a porcine model.

BACKGROUND: The procedure for prolapsing hemorrhoids (PPH) is a new surgical method for the treatment of symptomatic hemorrhoids. In cases of recurrent prolapse, the performance of a second PPH may result in a ring of mucosa and submucosa between the two circular staple lines. In this study, we used a porcine model to assess whether PPH can be safely performed twice. METHODS: Five adult pigs underwent two PPH procedures in one session, leaving a ring of approximately 1 cm of mucosa between the two staple lines. One month later, the pigs were examined under anesthesia. The anal canal was assessed using the following four methods: (a) clinical examination, (b) evaluation of mucosal blood perfusion at different levels of the anal canal via a laser Doppler flow detector, (c) measurement of concentrations of hydroxyproline and collagen to check for fibrosis, and (d) histopathological examination. RESULTS: At the completion of the study period, all five pigs showed no clinical evidence of anorectal dysfunction. On examination under anesthesia 1 month after surgery, there was no evidence of anal stenosis in any of the pigs. The mean mucosal blood flow between the two staple lines did not differ significantly from the flow measured proximally and distally (394 vs 363 and 339 flow units, respectively; p = NS). The collagen levels, based on hydroxyproline concentration, were 81 mcg/mg between the staple lines, compared to 82 and 79 proximally and distally, respectively ( p = NS). There was no significant difference in degree of fibrosis, as assessed histopathologically, between specimens taken from the ring between the staple lines and specimens taken from the area external to the staple lines. CONCLUSIONS: The results of this porcine model suggest that a second synchronous PPH is feasible. A controlled experience involving human subjects is required to determine the safety and usefulness of this technique in cases of metachronous application for recurrent or residual hemorrhoids.

Electromyographic findings of paradoxical puborectalis contraction correlate poorly with cinedefecography.

BACKGROUND: Both intra-anal sponge electromyography (SEMG) and needle electromyography (NEMG) are used to diagnose paradoxical puborectalis contraction (PPC). The aim of this retrospective study was to assess the correlation among SEMG and NEMG and cinedefecography (CD) in the diagnosis of PPC. METHODS: Between 1992 and 1999, a total of 261 constipated patients underwent both CD and EMG: 64 had NEMG while 197 had SEMG. PPC was diagnosed by EMG when there was failure to achieve a significant decrease in electrical activity of the puborectalis muscle during attempted evacuation. CD criteria for PPC included lack of straightening of the anorectal angle or persistence of the puborectalis impression during evacuation. CD was considered diagnostic and EMG results were thus compared with those of CD. Agreement was calculated using the kappa statistics (kappa) for concordance. RESULTS: Both NEMG and SEMG had low positive predictive rates (33% in NEMG, 28% in SEMG) and high negative predictive rates (91% in NEMG, and 78% in SEMG) when correlated with CD findings. Agreement between NEMG and CD was noted in 46 of 64 patients (72%, kappa=0.274) while there was agreement between SEMG and CD in 120 of 197 patients (61%; kappa=0.067); p>0.05 needle vs. sponge. CONCLUSION: Although both NEMG and SEMG have a low positive predictive values, they have high negative predictive value for PPC. Therefore, neither NEMG nor SEMG alone are optimal tests for diagnosing the presence of PPC.

Colonoscopy: why are general surgeons being excluded?

BACKGROUND: The role of surgeons as endoscopists has been extensively debated in the literature, with conflicting studies published regarding the safety and efficacy of surgeons performing colonoscopies. A multitude of medical federations and societies have set various standards for granting endoscopy privileges, many with a bias against general surgeons [1, 3]. We reviewed the colonoscopy experience at our institution to evaluate differences between gastroenterologists (GI) and general (GS) and colorectal surgeons (CRS) in procedure times and complication and cecal intubation rates. METHODS: Between January 2000 and July 2002, 5237 colonoscopies were performed at our institution. The data for procedure times, completion, and complication rates were collected in a prospective database. Complications were defined as perforation, bleeding, and postpolypectomy syndrome. Incomplete colonoscopies due to colitis, poor bowel preparation, or tumor obstruction were excluded. Chi-squared test was used to compare complication and cecal intubation rates between the three groups. Median procedure times were compared using the Kruskall-Wallis and Dunn's pairwise tests. A significant p-value was defined as <0.05. RESULTS: No differences in the complication rate was noted between the three groups: GI (0.12%), CRS (0.15%), and GS (0.11%) ( p = 0.99). There was a trend toward a lower incomplete colonoscopy rate in the GS group compared to CRS and GI: 0.32% vs 0.84% and 0.36%, respectively ( p = 0.07). The median colonoscopy times for GS (29 min), however, were shorter than for GI (34 min, p < 0.001) or CRS (31 min, p < 0.001). CONCLUSION: General surgeons perform colonoscopies expeditiously, with as low a morbidity rate and as high a completion rate as their gastroenterology or colorectal surgery colleagues. As the results of this study confirm, general surgeons should not be excluded from endoscopy suites.

Screening colonoscopy in the asymptomatic 50- to 59-year-old population.

BACKGROUND: In an effort to decrease the death rate from colorectal cancer, a multitude of medical societies and task forces recommend routine screening for colorectal cancer beginning at age 50. Yet, there is no consensus as to the best and most cost-effective screening method. Medicare now pays for screening colonoscopies for its average risk beneficiaries [3]. Many insurance companies, however, will not cover this test in younger patients. We therefore reviewed our institution's colonoscopy experience with asymptomatic 50- to 59-year-olds, with negative fecal occult blood tests and negative family histories. METHODS: Between January 1999 and January 2002, 4779 colonoscopies were performed at our institution. The charts for 619 persons 50-59 years of age were retrospectively reviewed, with 91 patients meeting the strict requirements of this study. We defined polyps with high-grade neoplasias as those with villous or tubulovillous components, and cancerous lesions included those with carcinoma in situ. The distal colon was defined as the rectum and sigmoid colon. RESULTS: There was a 58% incidence of neoplastic polyps in this younger asymptomatic population. More than 4% of our subjects had high-grade neoplasias or cancerous lesions. In the absence of any distal findings, flexible sigmoidoscopy would have missed up to 38% of these polyps. CONCLUSIONS: The findings generally support the recommendations by the American College of Gastroenterology for average-risk patients to preferentially undergo a screening colonoscopy at age 50 in lieu of other methods.

Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group.

PURPOSE: Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial. METHODS: A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14-day diaries. RESULTS: There was one treatment-related death. One hundred eighty-nine adverse events occurred in 91 patients (74 percent). Forty-nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty-three percent of patients without pre-existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty-six percent were not improved, worsened, or exited. In patients with pre-existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy-eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed. CONCLUSIONS: Objective improvement can be demonstrated in the majority of patients with end-stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

Risk factors for morbidity and mortality after colectomy for colon cancer.

PURPOSE: Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers. METHODS: The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications. RESULTS: A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, "do not resuscitate" status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin. CONCLUSIONS: Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.

Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.