Can normalized carcinoembryonic antigen following neoadjuvant chemoradiation predict tumour recurrence after curative resection for locally advanced rectal cancer?

AIM: The aim of this work was to evaluate whether normalized carcinoembryonic antigen (CEA) following neoadjuvant chemoradiation predicts the prognosis following curative resection in locally advanced rectal cancer. METHOD: Patients who underwent neoadjuvant chemoradiation and curative resection for locally advanced rectal cancer between 2010 and 2015 were divided into three groups: Group A (n = 119, normal-to-normal): normal CEA before and after neoadjuvant chemoradiation; Group B (n = 37, high-to-normal): elevated CEA before and normal CEA after neoadjuvant chemoradiation; Group C (n = 36, high-to-high): elevated CEA before and after neoadjuvant chemoradiation. Overall and disease-free survival were compared. Univariate and multivariate analyses identified potential predictors for recurrence. RESULTS: One hundred and ninety two patients [median age 59 years (range 31-87), 65.1% male] were identified: 54.7% had low rectal cancer: 12.5% were clinical stage T4 and 70.3% were clinically node positive; 21.9% achieved complete pathological response; 24.5% had abdominoperineal resection (APR); and 70.3% underwent adjuvant chemotherapy following curative resection. Significantly more patients in Group C underwent APR (p = 0.0209), had advanced pathological T stage (P = 0.0065) and a higher prevalence of perineural invasion (p = 0.0042). Overall and disease-free survival were significantly higher for Group A than for Group C [hazard ratio (HR) = 4.32, 95% CI = 1.66-11.21, p = 0.0026 and HR=2.68, 95% CI = 1.33-5.40, p = 0.0057, respectively]. No significant difference was noted between Groups A and B for overall (p = 0.0591) or disease-free (p = 0.2834) survival. Another risk factor associated with recurrence and death was clinical T4 stage; nodal positivity was a risk factor only for recurrence. CONCLUSION: Elevated CEA after neoadjuvant chemoradiation and clinical stage T4 disease were unfavourable predictors for overall and disease-free survival. Normalized CEA during neoadjuvant chemoradiation may serve as a prognosticator, although pretreatment CEA may significantly affect survival.

How reliable is laparoscopic colorectal surgery compared with laparotomy for octogenarians?

BACKGROUND: Due to the current increased longevity in the elderly population and the increased size of that population, major abdominal intervention is more frequently performed among octogenarians. This study aimed to compare the surgical and postoperative outcomes of laparoscopic colorectal resections with those of open surgery in the octogenarian population. METHODS: Retrospective analysis based on a prospectively maintained database of octogenarians who underwent laparoscopic or open elective colorectal resections from 2001 to 2008 was performed. Diagnosis, comorbidities, operative data, and early postoperative complications are analyzed in this report. RESULTS: Colon resection was performed for 199 octogenarians, using laparotomy for 116 patients (group 1) and laparoscopic surgery for 83 patients (group 2). The mean age was 84.3 years for the laparotomy patients and 84.7 years for the laparoscopic patients. The American Society of Anesthesiology (ASA) scores was comparable between groups 1 and 2. Colorectal adenoma was the most common indication for surgery in both groups: for 77.6% of the group 1 patients and 54.2% of the group 2 patients. Right colectomy was the most frequently performed operation in group 2: for 57.8% of the group 2 patients and 31% of the group 1 patients (p = 0.0003). Open resections had a higher mean blood loss in both group 1 (286 ml) and group 2 (152 ml) (p = 0.0002), and more patients required intraoperative transfusions (p = 0.005) despite similar operative times. The conversion rate in the laparoscopic group was 25.3%. The patients in the laparoscopic group had less morbidity, both overall and clinically, than the open group (p < 0.05). The median hospital stay was 8 days in group 1 and 6 days in group 2 (p = 0.0065). The rate of major surgical complications was similar in the two groups of patients: 6% in group 1 and 4.8% in group 2. The reoperation rate was 2.6% in group 1 and 3.6% in group 2 (p > 0.05). The mortality rate was 3.4% in group 1 and 2.4% in group 2. CONCLUSIONS: Laparoscopic colorectal resection was effective and safe for octogenarians, with less blood loss and faster postoperative recovery. The morbidity rate is lower than for traditional laparotomy.

Anal fistula plug: initial experience and outcomes.

PURPOSE: This study was designed to analyze the efficacy of the Cook Surgisis AFP anal fistula plug for the management of complex anal fistulas. METHODS: This was a retrospective review of all patients prospectively entered into a database at our institution who underwent treatment for complex anal fistulas using Cook Surgisis AFP anal fistula plug between July 2005 and July 2006. Patient's demographics, fistula etiology, and success rates were recorded. The plug was placed in accordance with the inventor's guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. RESULTS: Thirty-five patients underwent 39 plug insertions (22 men; mean age, 46 (range, 15-79) years). Three patients were lost to follow-up, therefore, 36 procedures to be analyzed. The fistula etiology was cryptoglandular in 31 (88.6 percent) patients and Crohn's disease associated in the other 4 (11.4 percent). There were 11 smokers and 3 patients with diabetes. The mean follow-up was 126 days (standard = 69.4). The overall success rate was 5 of 36 (13.9 percent). One of the four Crohn's disease-associated fistulas healed (25 percent) and 4 of 32 (12.5 percent) procedures resulted in healing of cryptoglandular fistulas. In 17 patients, further procedures were necessary as a result of failure of treatment with the plug. The reasons for failure were infection requiring drainage and seton placement in 8 patients (25.8 percent), plug dislodgement in 3 (9.7 percent), persistent drainage/tract and need for other procedures in 20 patients (64.5 percent). CONCLUSIONS: The success rate for Surgisis AFP anal fistula plug for the treatment of complex anal fistulas was (13.9 percent), which is much lower than previously described. Further analysis is needed to explain significant differences in outcomes.

Factors associated with failure of the artificial bowel sphincter: a study of over 50 cases from Cleveland Clinic Florida.

PURPOSE: This study investigated the risk factors related to artificial bowel sphincter infection, complications, and failure. METHOD: Complications may occur at any time after artificial bowel sphincter implantation. Early-stage complication is defined as any complications that occurred before artificial bowel sphincter activation, whereas late-stage complications are defined as any complications that occurred after device activation. Assessment of the outcomes of all artificial bowel sphincter operations included evaluation of factors related to patient demographics, operative procedures, and postoperative events. RESULT: From January 1998 to May 2007, 51 artificial bowel sphincter implantations were performed in 47 patients (43; 84.3% female) with a mean age of 48.8 +/- 12.5 (range, 19-79) years and a mean incontinence score of 18 +/- 1.4 (range, 0-20). In 24 patients (54.5%), the etiology of incontinence was secondary to imperforate anus; 15 (24.2%) patients had obstetric injury or anorectal trauma. Twenty-three (41.2%) artificial bowel sphincter implantations became infected, 18 (35.3%) of which developed early-stage infection, whereas 5 (5.9%) had late-stage infection. One patient in the latter group had associated erosion, and two patient had fistula formation. Late-stage complications continued to increase with time. Multivariate analysis revealed that the time between artificial bowel sphincter implantation and first bowel movement and a history of perineal sepsis were independent risk factors for early-stage artificial bowel sphincter infection. CONCLUSION: The time from implantation to first bowel movement and history of perineal infection were risk factors for early-stage artificial bowel sphincter infection and failure. Late-stage failures were more often the result of device malfunction and indicated the need for mechanical refinement.

Conversion in laparoscopic surgery: does intraoperative complication influence outcome?

BACKGROUND: Conversion from laparoscopy to laparotomy can be expected in a variable percentage of surgeries. Patients who experience conversion to a laparotomy may have a worse outcome than those who have a successfully completed laparoscopic procedure. This study aimed to compare the outcomes of converted cases based on whether the case was a reactive conversion (RC, due to an intraoperative complication such as bleeding or bowel injury) or a preemptive conversion (PC, due to a lack of progression or unclear anatomy). METHODS: All laparoscopic colorectal procedures converted to a laparotomy were retrospectively reviewed from data prospectively entered into an institutional review board-approved database. Patients who underwent an RC were matched with patients who underwent a PC according to age, gender, body mass index (BMI), and diagnosis. Patients who underwent a laparoscopic colorectal resection (LCR) were taken as the control group. The incidence and nature of postoperative complications, the time to liquid or regular diet, and the length of hospital stay were recorded. RESULTS: Of 962 laparoscopic procedures performed between 2000 and 2007, 222 (23.1%) converted to a laparotomy were identified. The 30 patients who had undergone an RC were matched with 60 patients who had undergone a PC and 60 patients who had undergone an LCR. The reasons for RC were bleeding in 14 cases, bowel injury in 6 cases, ureteric damage in 3 cases, splenic injury in 3 cases, and other complications in 4 cases. The patients who had undergone RC were more likely to have experienced a postoperative complication (50% vs 27%; p = 0.028), required longer time to toleration of a regular diet (6 vs 5 days; p = 0.03), and stayed longer in the hospital (8.1 vs 7.1 days; p = 0.080). CONCLUSION: Preemptive conversion is associated with a better outcome than reactive conversion. Based on this finding, it appears preferable for the surgeon to have a low threshold for performing PC rather than awaiting the need for an RC.

Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients.

BACKGROUND: The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. MATERIAL AND METHODS: A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). RESULTS: Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. CONCLUSION: The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

The effect of colorectal surgery in female sexual function, body image, self-esteem and general health: a prospective study.

OBJECTIVE: To evaluate women's sexual function, self-esteem, body image, and health-related quality of life after colorectal surgery. SUMMARY BACKGROUND DATA: Current literature lacks prospective studies that evaluate female sexuality/quality of life after colorectal surgery using validated instruments. METHODS: Sexual function, self-esteem, body image, and general health of female patients undergoing colorectal surgery were evaluated preoperatively, at 6 and 12 months after surgery, using the Female Sexual Function Index, Rosenberg Self-Esteem scale, Body Image scale and SF-36, respectively. RESULTS: Ninety-three women with a mean age of 43.0 +/- 11.6 years old were enrolled in the study. Fifty-seven (61.3%) patients underwent pelvic and 36 (38.7%) underwent abdominal procedures. There was a significant deterioration in overall sexual function at 6 months after surgery, with a partial recovery at 12 months (P = 0.02). Self-esteem did not change significantly after surgery. Body image improved, with slight changes at 6 months and significant improvement at 12 months, compared with baseline (P = 0.05). Similarly, mental status improved over time with significant improvement at 12 months, with values superior than baseline (P = 0.007). Physical recovery was significantly better than baseline in the first 6 months after surgery with no significant further improvement between 6 and 12 months. Overall, there were no differences between patients who had abdominal procedures and those who underwent pelvic dissection, except that patients from the former group had faster physical recovery than patients in the latter (P = 0.031). When asked about the importance of discussing sexual issues, 81.4% of the woman stated it to be extremely or somewhat important. CONCLUSION: Surgical treatment of colorectal diseases leads to improvement in global quality of life. There is, however, a significant decline in sexual function postoperatively. Preoperative counseling is desired by most of the patients.

Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study.

BACKGROUND: Narcotics are routinely used to decrease postoperative pain after laparotomy. But they are associated with unwarranted side effects. The aim of this study was to assess the effectiveness of local perfusion of bupivacaine in decreasing narcotic consumption after midline laparotomy. STUDY DESIGN: We performed a prospective, randomized, double blind study involving patients who underwent a midline laparotomy with subsequent wound closure. Patients were randomized to receive a 72-hour continuous wound perfusion through the ON-Q pain management system (I Flow Corporation) of the local anesthetic bupivacaine (0.5%, study group) or 0.9% NaCl (control group). In addition, all patients received standardized intraoperative analgesia and postoperative morphine patient-controlled analgesia. Total postoperative analgesic requirement, pain control, recovery of bowel function, and complications were recorded. RESULTS: Seventy patients were recruited: 35 in the study group (mean age, 55.7 years) and 35 in the control group (mean age, 58.8 years). There was no difference in overall postoperative pain scores. Patients in the study group reported earlier ambulation as compared with the control group. Mean (+/-SD) daily narcotic requirements were significantly less in the study group versus the control group (33.7+/-32 mg versus 60.1+/-62 mg, respectively; p=0.03). Patients in the study group made 50% fewer attempts to receive patient-controlled analgesia (p=0.011). But there was no significant difference in length of hospitalization or time to first bowel movement. CONCLUSIONS: This preliminary pilot study revealed that the ON-Q pain management system after midline laparotomy, as part of a multimodal approach, is an effective approach to postoperative pain control.

Surgical management of pouch-vaginal fistula after restorative proctocolectomy.

BACKGROUND: Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. METHODS: After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. RESULTS: The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. CONCLUSIONS: Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Lengthening of small bowel mesentery: stepladder incision technique.

The surgical option of choice in most patients with mucosal ulcerative colitis or familial adenomatous polyposis is restorative proctocolectomy with ileal pouch anal anastomosis. The tension-free anastomosis is one of the most critical steps but may be technically difficult or impossible in some patients because of shortened small bowel mesentery. Various techniques have been described to increase the length of small bowel mesentery. These techniques usually involve selective division of mesenteric blood vessels and meticulous dissection. We describe a new technique of stepladder transverse, transmesenteric incisions in the avascular windows of small bowel mesentery. This provides additional small bowel length without compromising blood supply to the pouch and a simple and safe method of increasing the length of small bowel mesentery. To date, no complications have been reported using this technique.

Correlating the Fecal Incontinence Quality-of-Life Score and the SF-36 to a proposed Ostomy Function Index in patients with a stoma.

Quality of life is affected by the creation of a stoma. To assess the validity of the Ostomy Function Index in patients with a stoma, a prospective survey was conducted from July 2000 to September 2001 among patients participating in local United Ostomy Association chapters (N = 99; 55 with a colostomy and 44 with an ileostomy). The Short Form 36 general health survey, Fecal Incontinence Quality of Life Scale, and the proposed Cleveland Clinic Florida Ostomy Function Index were used to assess general health and stoma function in patients with an ostomy. The average proposed function index score (7 = excellent function, 35 = poor function) was 11.97 (range 7 to 22). The proposed function Index correlated with the Fecal Incontinence Quality of Life Scale and the physical and mental component scales of the SF-36 (P < 0.05). The correlation between the proposed function index and the Fecal Incontinence Quality of Life Scale was stronger in colostomy than in ileostomy patients. With the exception of the SF-36 role-emotional domain in ileostomy patients, the function index correlated with all SF-36 scales (P <0.05) in both patient groups. The results of this study suggest that ostomy function is variable and correlates with quality of life and that the Fecal Incontinence Quality of Life Scale offers a limited assessment of quality of life in colostomy patients. The Cleveland Clinic Florida Ostomy Function Index offers an objective assessment of ostomy function that reflects on quality of life. Additional studies to refine measurement of quality of life in stoma patients are warranted.

Not all inflammation in the right lower quadrant is appendicitis: a case report of Escherichia coli O157:H7 with a review of the literature.

Although significant work has been presented on this subject in pediatric, infectious disease, and epidemiologic literature, there is a noteworthy lack of information on Escherichia coli O157:H7 in any surgical journals. As this disease can present with signs and symptoms often ascribed to the acute abdomen, it is imperative that the general surgeon, pediatric surgeon, and colorectal surgeon are all familiar with this infection and its clinical ramifications. A case report followed by a review of the literature is presented.

The association between late-onset fecal incontinence and obstetric anal sphincter defects.

HYPOTHESIS: Endoanal ultrasonographic results have demonstrated that clinically occult anal sphincter damage during vaginal delivery is common. This may or may not be associated with postpartum fecal incontinence (FI). Bayesian meta-analysis of the literature revealed that at least two thirds of obstetric sphincter disruptions are asymptomatic in the postpartum period. Women with postpartum asymptomatic sphincter damage may be at increased risk for FI with aging compared with those without sphincter injury. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: After excluding patients with other possible causes of FI, the histories of 124 consecutive women with late-onset FI after vaginal delivery were analyzed. MAIN OUTCOME MEASURES: Endoanal ultrasonographic findings, pudendal nerve terminal motor latency assessment, and anal manometric results. RESULTS: Eighty-eight women (71%) with a median of 3 vaginal deliveries had sphincter defects on endoanal ultrasonographic results. The mean incontinence score, squeeze and resting pressures, median age at last delivery, and median duration of FI were not significantly different between patients with and without sphincter defects. Pudendal neuropathy was more frequent in patients without sphincter defects (10 [30.3%], left side; 12 [36.4%], right side) than in patients with sphincter defects (12 [14.3%] and 16 [19.3%], respectively), with the difference nearly reaching statistical significance (P =.054 and P =.059, respectively). The median age at onset of FI in patients with a sphincter defect was 61.5 years vs 68.0 years in those without a sphincter defect, which was not statistically significant (P =.08). CONCLUSION: Analysis of the current patient population revealed that 88 women (71%) with late-onset FI after vaginal delivery had an anatomical sphincter defect. Thus, FI related to anal sphincter defects is likely to occur even in an elderly population who had experienced vaginal deliveries earlier in life.

Anal stenosis and mucosal ectropion.

Anal stenosis (AS) or stricture is defined as the loss of compliant natural elasticity of the anal opening, which then becomes abnormally tight and fibrous. It is a very disabling condition, worsened by the patient's embarrassment, but uncommon. The vast majority of cases are secondary to trauma, iatrogeny, inflammatory diseases, or neoplasia, or occur postradiation. Depending on the severity and level of involvement, AS can be classified as mild, moderate, or severe. Due to the rarity of this pathology and the different referral patterns among institutions, the etiology ranges widely between published reports. There are multiple surgical techniques that have been described for the correction or improvement of AS. Moderate or severe AS is the usual indication for operative treatment.

Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons.

The utility of antibiotic and mechanical preparation for colorectal surgery is controversial, and numerous different regimens are used. The aim of this study was to detect trends in preparation for surgery among American colon and rectal surgeons. Members of the American Society of Colon and Rectal Surgeons practicing in the United States were surveyed with a postal questionnaire regarding their routine preparations for colon and rectal surgery. Five hundred fifteen (40%) of the 1295 questionnaires sent were returned. Eighty-one per cent of the respondents had completed an accredited colorectal training program, and the average experience in practice was 13.7 (+/- 8.7) years. Half of the surgeons felt that prophylactic oral antibiotic is essential, 41 per cent felt it was doubtful, and 10 per cent considered oral prophylaxis unnecessary. Despite these statements 75 per cent of the surgeons routinely utilized oral antibiotics (96% of them used a combination of two drugs), 11 per cent used them selectively, and only 13 per cent omitted oral prophylaxis from their practice. Similarly although the usefulness of intravenous antibiotics was questioned by 11 per cent of the surgeons 98 per cent routinely used them. The average number of postoperative doses was two (+/- 1.9). Although 10 per cent of the surgeons questioned the importance of mechanical preparation more than 99 per cent routinely used it. Forty-seven per cent of the surgeons used sodium phosphate, 32 per cent used polyethylene glycol, and 14 per cent alternated between these two options. We conclude that although the use of oral antibiotic prophylaxis for colorectal surgery is controversial among surgeons it is still routinely practiced by 75 per cent. Intravenous antibiotic prophylaxis and mechanical cleansing, however, are still a dogma and almost invariably used. There is a trend toward the use of a shorter course of postoperative intravenous antibiotics and the use of sodium phosphate for mechanical cleansing.

Colorectal cancer screening: do they practice what they preach?

INTRODUCTION: Compliance for voluntary colorectal cancer (CRC) screening reported by the American Society of Colon and Rectal Surgeons (ASCRS) is>85%. This high rate is assumed to be the result of heightened awareness of CRC. The purpose of the present paper was to determine if observed participation rates in the USA are the result of increased awareness of CRC alone. METHODS: Postal survey of Colorectal Surgical Society of Australia (CSSA). RESULTS: A response rate of 65% (52\80) was observed. As in the ASCRS, the majority of members support screening (94%); but 4% (2\52) reported that they do not advocate CRC screening, which was lower than that observed in the ASCRS survey (P = 0.03). A total of 94% support screening of baseline risk (BLR) patients at age 50 or less. Support was similar for annual fecal occult blood testing (FOBT; CSSA 54% vs ASCRS 56%, P = NS) for patients with BLR, but much less support for colonoscopy every 10 years (CSq10) was observed (CSSA 31% vs ASCRS 68%, P < 0.01). Similar to the ASCRS, CS every 5 years (CSq5) was the most common strategy advocated to patients with a family history of polyps (CSSA 75% vs ASCRS 78%, P = NS) and cancer (CSSA 94% vs ASCRS 94%, P = NS), respectively. A total of 25% (13\52) of CSSA members report participating in CRC screening, compared to the 55% reported by the ASCRS (P < 0.01). As in the ASCRS, CSq5 (69%) was the most common form of screening undergone. None of the CSSA members were being screened with more than one test, compared to the 46% reported by the ASCRS (P < 0.01). Of those who had not been screened, 82%(31\38) reported that they do plan to undergo CRC screening compared to 99% reported by the ASCRS (P < 0.05). CONCLUSION: Screening compliance is significantly higher in the ASCRS than in the CSSA. Awareness of CRC is not the only obstacle to improving screening compliance.

Recurrence rates at minimum 5-year follow-up: laparoscopic versus open sigmoid resection for uncomplicated diverticulitis.

The aim of the study was to compare the impact of surgical access to sigmoid resection on recurrence rates in patients with uncomplicated diverticulitis of the sigmoid (UDS) at a minimum follow-up of 5 years. Recurrence after surgery was defined as left lower quadrant pain, fever, and leucocytosis with consistent CT and enema findings on admission and at 6 weeks, respectively. Outcome measures included splenic flexure mobilization, specimen length, inflammation at proximal resection margin, and presence of teniae coli at distal resection margin. Seventy-nine patients undergoing laparoscopic sigmoid resection (LSR) were compared with 79 matched controls with open sigmoid resection (OSR) operated on at 2 institutions during the same period. Patients were well matched for age, gender, body mass index, ASA grading, and symptoms duration, but not for follow-up length (81.9 versus 86.9 months, P = 0.046). Differences in rates of splenic flexure mobilization (19 versus 41, P < 0.001), specimen length (16.1 versus 18.3 cm, P = 0.048), inflammation at proximal resection margin (21 versus 4, P < 0.001), and teniae coli at distal resection margin (4 versus 53, P < 0.001) did not show an impact on recurrence rates when comparison was made between LSR and OSR. Three LSR patients and 7 OSR patients had 1 recurrence (P = 0.19). There were no significant differences in rates of flexure mobilization, specimen length, and rates of inflammation present at proximal resection margin in 10 recurring and 145 non-recurring patients. The rate of teniae coli present at distal resection margin was significantly increased in recurring patients (7 versus 43, P = 0.03). Median time of recurrence after surgery was 29 (range 18-74) months. Two of 11 recurrences occurred after 5 years. Surgical access to sigmoid resection for UDS is unlikely to have an impact on recurrence rates provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid.

Slow transit constipation: a review of a colonic functional disorder.

Constipation is a common gastrointestinal complaint that can cause significant physical and psychosocial problems. It has been categorized as slow transit constipation, normal transit constipation, and obstructed defecation. Both the definition and pathophysiology of constipation are unclear, but attempts to describe each of the three types have been made. Slow transit constipation, a functional colonic disorder represents approximately 15 to 30% of constipated patients. The theorized etiologies are disorders of the autonomic and enteric nervous system and/or a dysfunctional neuroendocrine system. Slow transit constipation can be diagnosed with a complete history, physical exam, and a battery of specific diagnostic studies. Once the diagnosis is affirmed and medical management has failed, there are several treatment options. Biofeedback, sacral nerve stimulation, segmental colectomy, and subtotal colectomy with various anastomoses have all been used. Of those treatment options, a subtotal colectomy with ileorectal anastomosis is the most efficacious with the data to support its use.

Should ileoanal pouch surgery be staged for patients with mucosal ulcerative colitis on immunosuppressives?

INTRODUCTION AND OBJECTIVE: Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery. MATERIALS AND METHODS: A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis. RESULTS: Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate. CONCLUSION: This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery.

Squamous cell carcinoma of the rectum in ulcerative colitis: case report and review of the literature.

The majority of colorectal carcinomas diagnosed are adenocarcinomas. Squamous cell carcinomas (SCC) of the rectum are rare tumors, and were reported as rare complication of inflammatory bowel disease. Surgery is the most effective therapy; and adjuvant chemotherapy and radiotherapy should also be considered. We report two cases of ulcerative colitis-associated SCC of the rectum. The lesions were treated with chemoradiotherapy with complete response.