Outcomes following surgery for perforating Crohn's disease.

BACKGROUND: The most common indications for surgery for patients with ileocolic Crohn's disease are fibrostenotic or perforating disease. The objective was to compare surgical outcomes of patients with perforating versus non-perforating disease following ileocolic resection. METHODS: This was a retrospective review of all patients who had their first ileocolic resection between 1990 and 2010, identified from a prospectively maintained inflammatory bowel disease database. Demographic information, preoperative medication, intraoperative findings and postoperative outcome data were collected. Outcomes in patients who had an abscess drained before surgery or were found to have a fistula or abscess at surgery or at pathology were compared with outcomes in all others. RESULTS: A total of 434 patients (56·2 per cent women) were included, 293 with perforating and 141 with non-perforating disease. Median age, tobacco use, and preoperative steroid and biological agent use were similar in the two groups. Forty patients (13·7 per cent) in the perforating group had abscesses drained before surgery and 251 patients had at least one fistula, most commonly to the sigmoid colon. Patients with perforating disease were more likely to require preoperative total parenteral nutrition, need another resection, have an ileostomy and a longer mean postoperative stay, and less likely to undergo a laparoscopic procedure. Patients in this group also developed more postoperative abscesses or leaks (4·8 versus 0 per cent; P = 0·006). The reoperation rate was similar (3·1 versus 0·7 per cent; P = 0·178). CONCLUSION: Patients with penetrating Crohn's disease are more likely to require a more complex procedure, and an ileostomy, and to a have longer postoperative stay.

Long-term outcome of colectomy and ileorectal anastomosis for Crohn's colitis.

BACKGROUND: Ileorectal anastomosis is an important surgical option for patients with Crohn's colitis with relative rectal sparing. OBJECTIVE: This study aimed to audit outcomes of ileorectal anastomosis for Crohn's and factors associated with proctectomy and reoperation. DESIGN: This retrospective study involved a chart review and contacting patients. SETTINGS: Patients with Crohn's colitis who had an ileorectal anastomosis were identified from the Mount Sinai Hospital Inflammatory Bowel Disease Database. PATIENTS: Demographics, operative and perioperative outcomes, and reoperative data were collected. MAIN OUTCOME MEASURES: Five- and 10-year Kaplan-Meier survival estimates and 95% confidence intervals were calculated for survival from proctectomy and Crohn's-related revisional surgery. Cox proportional hazards models were used to model the hazards of proctectomy and Crohn's-related revision on the clinical characteristics of patients. RESULTS: Eighty-one patients had an ileorectal anastomosis for Crohn's disease from 1982 to 2010. The most common indications for surgery were failed medical management (60/81, 74.1%) and a stricture causing obstruction (14/81, 17.3%). Seventy-seven percent (n = 62) had a 1-stage procedure, whereas 23% (n = 19) had a 2-stage procedure (colectomy followed by ileorectal anastomosis). The overall anastomotic leak rate was 7.4% (n = 6). Fifty-six patients had a functioning ileorectal anastomosis at the time of follow-up. At 5 and 10 years, 87% (95% CI: 75.5-93.3) and 72.2% (95% CI: 55.8-83.4) of individuals had a functioning ileorectal anastomosis. Eighteen patients required proctectomy for poor symptom control, whereas 11 patients required a small-bowel resection plus redo-ileorectal anastomosis. The mean time to proctectomy from the original ileorectal anastomosis was 88.3 months (SD = 62.1). Smoking was associated with both proctectomy (HR 3.93 (95% CI: 1.46-10.55)) and reoperative surgery (HR 2.12 (95% CI: 0.96-4.72)). LIMITATIONS: : This study was retrospective. CONCLUSIONS: Ileorectal anastomosis is an appropriate operation for selected patients with Crohn's colitis with sparing of the rectum. However, patients must be counseled that the reoperation rate and/or proctectomy rate is approximately 30%.

Transatlantic comparison of the competence of surgeons at the start of their professional career.

BACKGROUND: Although the objective in European Union and North American surgical residency programmes is similar-to train competent surgeons-residents' working hours are different. It was hypothesized that practice-ready surgeons with more working hours would perform significantly better than those being educated within shorter working week curricula. METHODS: At each test site, 21 practice-ready candidate surgeons were recruited. Twenty qualified Canadian and 19 qualified Dutch surgeons served as examiners. At both sites, three validated outcome instruments assessing multiple aspects of surgical competency were used. RESULTS: No significant differences were found in performance on the integrative and cognitive examination (Comprehensive Integrative Puzzle) or the technical skills test (Objective Structured Assessment of Technical Skill; OSATS). A significant difference in outcome was observed only on the Patient Assessment and Management Examination, which focuses on skills needed to manage patients with complex problems (P < 0.001). A significant interaction was observed between examiner and candidate origins for both task-specific OSATS checklist (P = 0.001) and OSATS global rating scale (P < 0.001) scores. CONCLUSION: Canadian residents, serving many more working hours, perform equivalently to Dutch residents when assessed on technical skills and cognitive knowledge, but outperformed Dutch residents in skills for patient management. Secondary analyses suggested that cultural differences influence the assessment process significantly.

A new assessment tool: the patient assessment and management examination.

BACKGROUND: The major goal of certification is to assure the public that the candidate is competent in all facets required of the position. The patient assessment and management examination (PAME) was developed to enable a more comprehensive assessment of competence in the practice of surgery. METHODS: A six-station, 3-hour, standardized-patient-based evaluation was developed. Each station was scored using a set of five-point global rating scales. PAME results were compared to the last two in training evaluation reports (ITER), the clinical knowledge component of the ITER (ITER-CK), an in-house oral examination (OE), and the Canadian Association of General Surgeons' multiple-choice examination (CAGS). RESULTS: Eighteen senior general surgery residents were evaluated. Overall reliability was 0.70 (Cronbach's alpha). Fifth-year residents scored significantly better than fourth-year residents (t = 3.062; p = 0.0074), with 1 year of training accounting for 37% of the variance in scores. Correlations between the PAME and each of the other measures were ITER, 0.24; ITER-CK, 0.38; OE, -0.13; and CAGS, 0.061, with the PAME demonstrating better reliability and stronger evidence of validity than any other. CONCLUSIONS: The PAME had better psychometric properties than other measures and assessed areas often not evaluated. This type of evaluation may be useful for feedback, remediation, or certification decisions.

Comparing checklists and databases with physicians' ratings as measures of students' history and physical-examination skills.

PURPOSE: To compare two methods of rating students' performances on history and physical examination: (1) by using checklists completed by standardized patients (SPs) and databases completed by students, and (2) by using ratings of students by three physicians for each SP-student encounter. METHOD: Four cases were chosen for the study, and 30 students were examined per case. The students were all in their fourth year at the Southern Illinois University School of Medicine in the spring of 1991. Two of the cases had both checklists and databases, and the remaining two had databases only. Each SP-student encounter was videotaped and was viewed independently by three physicians unfamiliar with the contents of the checklists and databases. The physicians' pooled ratings were then compared with the checklist and database scores. Uncorrected and corrected correlations were obtained, with the generalizability coefficient used as the index of reliability. RESULTS: Interrater generalizability of physicians' ratings was very good, ranging from .65 to .93 for overall ratings. Generalizability of physicians' ratings pooled across the four cases was .85. Checklist scores tended to correlate higher with physicians' ratings than did database scores: across the cases, correlation coefficients between physicians' ratings and checklist scores and database scores were .65 and .39, respectively. CONCLUSION: The checklist scores correlated strongly with the physicians' ratings of history and physical-examination skills, providing some evidence of validity for their use. The checklist scores correlated much better with the physicians' ratings than did the database scores. Possible explanations for this finding are discussed.

Toward reliable operative assessment: the reliability and feasibility of videotaped assessment of laparoscopic technical skills.

BACKGROUND: Decision making on the competency of surgical trainees to perform laparoscopic procedures has been hampered by the lack of reliable methods to evaluate operative performance. The goal of this study was to develop a feasible and reliable method of evaluation. METHODS: Twenty-nine senior surgical residents were videotaped performing a low anterior resection and a Nissen fundoplication in a pig. Ten blinded laparoscopists rated the videos independently on two scales. Rating time was minimized by allowing raters to fast-forward through the tapes at their discretion. Interrater reliability and the time required to rate a procedure were assessed. RESULTS: Rating time per procedure was a median of 15 min (range, 6-40). The mean interrater reliability for the two scales was 0.74. CONCLUSIONS: The use of videotapes of operations enabled multiple raters to assess a performance reliably and shortened assessment times by 80%. This assessment technique shows potential as a means of evaluating the performance of advanced laparoscopic procedures by surgical trainees.

Comparison of hemorrhoidal treatments: a meta-analysis.

OBJECTIVE: To determine whether any method of hemorrhoid therapy has been shown to be superior in randomized trials. METHOD: A meta-analysis of all randomized controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. MAIN OUTCOME MEASURES: Response to therapy, the need for further therapy, complications and pain. RESULTS: Eighteen trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilatation of the anus (p = 0.0017) and associated with less need for further therapy (p = 0.034), no significant difference in complications (p = 0.60) but more pain (p < 0.001). Patients who underwent hemorrhoidectomy had a better response to treatment than did patients who were treated with rubber-band ligation (p = 0.001), although complications were greater (p = 0.02), as was pain (p < 0.0001). Rubber-band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (p = 0.005) and for hemorrhoids stratified by grade (grades 1 and 2, p = 0.007, grade 3, p = 0.042), with no difference in the complication rate (p = 0.35). Patients treated with sclerotherapy (p = 0.031) or infrared coagulation (p = 0.0014) were more likely to require further therapy than those treated with rubber-band ligation, although pain was greater after rubber-band ligation (p = 0.03 for sclerotherapy, p < 0.0001 for infrared coagulation). CONCLUSIONS: Rubber-band ligation is recommended as the initial mode of therapy for grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response, it is associated with more complications and pain than rubber-band ligation. Thus, it should be reserved for patients whose hemorrhoids fail to respond to rubber-band ligation.

Comparison of hemorrhoidal treatment modalities. A meta-analysis.

PURPOSE: The purpose of this study was to assess whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials. METHOD: A meta-analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain. RESULTS: A total of 18 trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilation of the anus (P = 0.0017), with less need for further therapy (P = 0.034), no significant difference in complications (P = 0.60), but significantly more pain (P < 0.0001). Patients undergoing hemorrhoidectomy had a better response to treatment than did patients treated with rubber band ligation (P = 0.001), although complications were greater (P = 0.02) as was pain (P < 0.0001). Rubber band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (P = 0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2; P = 0.007; Grade 3 hemorrhoids, P = 0.042), with no difference in the complication rate (P = 0.35). Patients treated with sclerotherapy (P = 0.031) or infrared coagulation (P = 0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation (P = 0.03 for sclerotherapy; P < 0.0001 for infrared coagulation). CONCLUSION: Rubber band ligation is recommended as the initial mode of therapy for Grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for patients who fail to respond to rubber band ligation.

Handsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis.

PURPOSE: Trials comparing handsewn with stapled anastomoses in colon and rectal surgery have not found statistical differences. Despite this, authors have differed in their conclusions as to which technique is superior. To help determine whether differences in patient outcomes are present, a meta-analysis of all trials was performed. METHOD: A meta-analysis of all randomized, controlled trials assessing handsewn and stapled colon and rectal anastomoses was done using a fixed-effects model. Outcome variables were mortality, technical problems, leak rates, wound infections, strictures, and cancer recurrence. Outcomes were assessed for all anastomoses involving the colon and for the subset of colorectal anastomoses. RESULTS: Thirteen distinct trials met the inclusion criteria. Intraoperative technical problems were more likely to occur with stapled than with handsewn anastomoses for all anastomoses (P < 0.0001) and for colorectal anastomoses (P < 0.001). Strictures were also more common following stapled anastomoses (P = 0.015 for all anastomoses; P = 0.028 for colorectal anastomoses). All other outcome measures, including mortality, clinical and radiologic leak rates, and local cancer recurrence rates showed no difference between groups. CONCLUSION: Although intraoperative technical problems and postoperative strictures were more common with stapled anastomoses, other outcome measures showed no difference between groups. Thus, both techniques are effective, and the choice may be based on personal preference.

Routine omission of nasogastric intubation after gastrointestinal surgery.

The need for routine nasogastric-tube decompression after gastrointestinal surgery has been challenged repeatedly for several years. To determine whether nasogastric intubation can be omitted routinely, 101 consecutive patients who underwent gastrointestinal surgery were managed prospectively without nasogastric tubes. Excluded were patients with complete bowel obstruction and those who required prolonged endotracheal intubation. These patients were compared with 101 retrospective controls who had nasogastric decompression routinely. There were four protocol violations in the prospective group (nasogastric tubes were left in place postoperatively) and one in the retrospective group (no nasogastric tube postoperatively), leaving 97 and 100 patients, respectively, for follow-up. The mean duration of hospitalization in comparable patients was 10.6 days in patients without decompression and 11.9 days in those with routine decompression. Subsequent nasogastric-tube insertion was required in nine patients who did not undergo routine decompression, compared with two patients who had routine decompression. There were no statistically significant differences in the rates of anastomotic leaks, wound disruptions and pulmonary or other complications between the two groups. The authors conclude that nasogastric decompression can be safely omitted as a routine part of postoperative care after gastrointestinal surgery.

Perioperative complications of splenectomy for hematologic disease.

A 15-year study of perioperative complications was carried out in 142 adults who underwent splenectomy for hematologic disease at the University of Alberta Hospital in order to obtain recent statistics on morbidity and mortality. The patients were grouped into four diagnostic categories: idiopathic thrombocytopenic purpura (71 patients), lymphoproliferative disorders (34 patients), myeloproliferative disorders (12 patients) and miscellaneous disorders (25 patients). Splenectomy was carried out for therapeutic reasons in 93% of patients and to establish a diagnosis in 7%. The overall complication rate was 22% (31 of 142) and the death rate was 6% (7 of 142). Infection accounted for 42% of the complications. Steroid or antibiotic therapy preoperatively did not significantly affect the infection rate. Drains, if removed within the first week, also did not affect the postoperative infection rate. Spleen size and the interaction between diagnosis and the presence of thrombocytopenia were predictors of the need for intraoperative transfusion.

Treatment of rectovaginal fistulas that has failed previous repair attempts.

PURPOSE: The purpose of this study was to assess results of treatment of rectovaginal fistulas (excluding pouch vaginal fistulas) that have failed previous attempts at repair. METHOD: A retrospective chart review of all patients presenting with nonhealing rectovaginal fistula was performed. RESULTS: Twenty eight patients with persistent fistulas were identified. In 18 patients the fistula was classified as simple, and in 10 the fistula was complex. Fourteen fistulas were secondary to obstetric injury, five were caused by Crohn's disease, and nine patients had miscellaneous etiologies for their fistulas. Of patients with persistent simple fistulas, 13 (72 percent) of the fistulas healed, 5 after advancement flaps, 5 following sphincteroplasty, and 3 after coloanal anastomoses. Of persistent complex fistulas, only four of ten (40 percent) healed, one following sphincteroplasty, one with coloanal anastomosis, and two after gracilis transposition. A total of 23 advancement flaps were done in 17 patients with five fistulas healing (29 percent). Sphincteroplasty and fistulectomy was successful in six of seven patients (86 percent). Coloanal anastomosis resulted in healing of four of six patients (67 percent) in whom it was attempted. Gracilis muscle transfer was successful in two of two patients (100 percent). CONCLUSION: Persistent rectovaginal fistula presents a difficult management problem. Choice of operation must be tailored to the underlying pathology and type of repair previously done. Advancement flap repair is generally not recommended for persistent complex fistulas or for simple fistulas that have failed a previous advancement flap repair.

Risk factors for pelvic pouch failure.

PURPOSE: This study was designed to identify factors associated with pelvic pouch failure. METHOD: A retrospective review of patients undergoing the pelvic pouch procedure with a minimum of 30 months follow-up was conducted. RESULTS: A total of 551 patients had pelvic pouch procedures from 1981 to 1992. Forty-nine patients (8.8 percent) have undergone pouch excision, and 9 (1.6 percent) have been defunctioned, for 58 (10.5 percent) patients with pouch failure. Cause of failure was leakage from the ileoanal anastomosis (IAA) in 21 (39 percent) patients, poor functional results in 13 (23 percent), pouchitis in 7 (12 percent), pouch leakage in 7 (12 percent), perianal disease in 7 (12 percent), and miscellaneous in 3 (5.2 percent). Nine of 22 patients (41 percent) had pouch failure during the first two years, with 2 of 147 patients (1 percent) having failure during the last two years of the study. The 58 patients whose pouches failed (Group 1) were compared with the 493 patients whose pouches did not fail (Group 2). Handsewn IAA (P < 0.001), tension on the IAA (P < 0.001), use of a defunctioning ileostomy (P < 0.01), a diagnosis of Crohn's disease (P < 0.001), and a leak from the pouch (P < 0.001) or the IAA (P < 0.001) were associated with pouch failure. Pouchitis was not a risk factor. CONCLUSION: The majority of pouch failures were caused by leaks at the IAA. Although the leak rate remained stable, leaks following a stapled anastomosis seemed to have a better prognosis than leaks following a handsewn anastomosis. Experience with the pouch procedure and the management of complications likely plays an important role in decreasing the risk of pouch failure.

Pregnancy, delivery, and pouch function after ileal pouch-anal anastomosis for ulcerative colitis.

PURPOSE: This study was designed to evaluate the pregnancies, method of delivery, and functional results of females with chronic ulcerative colitis who have an ileal pouch-anal anastomosis. METHODS: A mailed questionnaire was sent to all females with an ileal pouch-anal anastomosis for chronic ulcerative colitis. Information on the pregnancy, method of delivery, and outcome was collected. Those females who had a successful pregnancy and delivery were contacted by telephone to clarify results and determine pouch functional results. Other clinical information was obtained from the Mount Sinai Hospital Inflammatory Bowel Disease database. RESULTS: Thirty-eight subjects had 67 pregnancies. Of these, 29 subjects had 49 deliveries. There were 25 vaginal deliveries and 24 cesarean sections. There were two pouch-related complications during the pregnancies and four pouch-related complications postpartum. All were treated nonoperatively. Stool frequency and day and night incontinence were increased during pregnancy in most subjects, but after delivery, prepregnancy function was restored in 24 (83 percent) of them. Five subjects (17 percent) had some degree of permanent deterioration in pouch function. Of these, three had vaginal deliveries, and two had cesarean sections. Multiple births and birth weight were not found to adversely affect subsequent pouch function. CONCLUSION: Pregnancy is safe in females with ileal pouch-anal anastomosis. Functional results are altered almost exclusively during the third trimester, but pouch function promptly returns to prepregnancy status in most females. A small proportion of females have long-term disturbances in function, but these are not related to the method of delivery. Thus, the method of delivery should be dictated by obstetric considerations.