Local excision for T1 rectal tumours: are we getting better?

AIM: The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS). METHODS: Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed. RESULTS: Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P < 0.001). In unadjusted analysis, there was no significant difference in 5-year OS between the LE and RR groups (P = 0.639) and between the two LE time periods (P = 0.509), which was consistent with the adjusted analysis (LE vs RR, hazard ratio 1.05, 95% CI 0.92-1.20, P = 0.468; 2008-2010 LE vs 2011-2016 LE, hazard ratio 1.09, 95% CI 0.92-1.29, P = 0.321). Laparoscopic LE was associated with improved OS in the unadjusted analysis only (P = 0.006), compared to the open LE group (hazard ratio 0.94, 95% CI 0.78-1.12, P = 0.495). CONCLUSIONS: This study supports the use of a LE approach for T1 rectal tumours as a strategy to reduce surgical morbidity without compromising survival.

Survivorship care for early-stage colorectal cancer: a national survey of general surgeons and colorectal surgeons.

AIM: Few data are available on the optimal long-term care of early-stage colorectal cancer survivors, termed survivorship care. We aimed to investigate current practice in the management of patients following treatment for early-stage colorectal cancer. METHOD: We performed an internet survey of members of the American Society for Colon and Rectal Surgeons about several aspects of long-term care, including allocation of clinician responsibility, challenges with transitions to primary care physicians (PCPs), long-term care plan provision and recommended surgical follow-up duration. RESULTS: Overall, 251 surgeons responded. Surgeons reported taking primary responsibility for managing adverse surgical effects (93.2%) and surveillance testing (imaging and laboratories 68.6%, endoscopy 82.4%). Barriers to PCP handoffs included patient preference for surgical follow-up (endorsed by 76.6%) and inadequate communication with PCPs (endorsed by 36.9%). Approximately one-third of surgeons routinely provide survivorship care plans to PCPs; surgeons who received formal survivorship training were more likely to do so compared to those without such training (OR 3.29, 95% CI 1.57, 6.92). Although only 20.4% of surgeons follow their patients beyond 5 years, individuals in practice longer were more likely to continue long-term follow-up than those with ≤ 10 years of experience. CONCLUSIONS: This is the largest survey of surgeons regarding long-term management for early-stage colorectal cancer and highlights the potential for improved coordination with PCPs and increased implementation of survivorship care plans.

Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database.

AIM: The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS: A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION: Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.

Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status.

PURPOSE: Research examining effects of ostomy use on sexual outcomes is limited. Patients with colorectal cancer were compared on sexual outcomes and body image based on ostomy status (never, past, and current ostomy). Differences in depression were also examined. METHODS: Patients were prospectively recruited during clinic visits and by tumor registry mailings. Patients with colorectal cancer (N = 141; 18 past ostomy; 25 current ostomy; and 98 no ostomy history) completed surveys assessing sexual outcomes (medical impact on sexual function, Female Sexual Function Index, International Index of Erectile Function), body image distress (Body Image Scale), and depressive symptoms (Center for Epidemiologic Studies Depression Scale-Short Form). Clinical information was obtained through patient validated self-report measures and medical records. RESULTS: Most participants reported sexual function in the dysfunctional range using established cut-off scores. In analyses adjusting for demographic and medical covariates and depression, significant group differences were found for ostomy status on impact on sexual function (p < .001), female sexual function (p = .01), and body image (p < .001). The current and past ostomy groups reported worse impact on sexual function than those who never had an ostomy (p < .001); similar differences were found for female sexual function. The current ostomy group reported worse body image distress than those who never had an ostomy (p < .001). No differences were found across the groups for depressive symptoms (p = .33) or male sexual or erectile function (p values ≥ .59). CONCLUSIONS: Colorectal cancer treatment puts patients at risk for sexual difficulties and some difficulties may be more pronounced for patients with ostomies as part of their treatment. Clinical information and support should be offered.

Laparoscopic rectopexy.

Abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0-12% and fecal continence has been documented to improve in 3-75% of patients. As most patients are elderly and not always fit enough to undergo abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures have a recurrence of up to 38%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a laparoscopic rectopexy on 72-year-old lady with a 10-year history of fecal incontinence and mucosal rectal prolapse. Electronic supplementary material is available for this article at http://dx.doi.org/10.1007/s00464-006-0136-y.

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.

Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients.

BACKGROUND: Obesity is a relative contraindication to performing restorative proctocolectomy. The aim of this study was to assess the morbidity and functional results after restorative proctocolectomy in obese patients as compared to a matched cohort of non-obese patients. METHODS: 334 patients who had restorative proctocolectomy were reviewed; obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. 31 obese patients were matched to 31 non-obese patients for age, gender, steroid use, and diagnosis. Operative time, length of hospitalization, and both perioperative (< 6 weeks) and long-term morbidity (> 6 weeks), especially sepsis, were evaluated. RESULTS: The BMI was significantly higher in the obese group (33.7 vs 23.2) (p < 0.0001), and no difference was found between the obese and non-obese groups relative to the matched parameters of age, gender, steroid use and diagnosis. There was no difference in the rate of mucosectomy performed between the obese and non-obese patients (9.6% vs 3.2%, p = NS). 16% of the obese patients underwent one stage restorative proctocolectomies as compared to 10% in the non-obese group. Operative time was longer in the obese group (229 min vs 196 min; p = 0.02), but overall hospital length of stay was similar (9.7 days vs 7.7 days; p = 0.13). Perioperative morbidity was higher in obese patients (32% vs 9.6%, p = 0.058). However, there was no statistical significance in long-term morbidity (23% vs 32%, p = 0.57) at a mean follow-up of 51 months in the obese group and 53 months in the non-obese group. Obese patients had more stomal complications (10 vs 0%) and incisional hernias (13 vs 3%) (p = NS). Overall the pelvic sepsis-rate was significantly higher in the obese group (16 vs 0%; p < 0.05). 60% of the obese patients who developed pelvic sepsis had pouch-anal anastomosis performed without proximal fecal diversion. Mean bowel movements/24 hours, pad use, nocturnal evacuation, accidents/24 hours and incontinence scores were not statistically significant between the groups. CONCLUSION: Obese patients have a higher rate of pelvic sepsis and peri-operative morbidity when compared to a matched non-obese cohort of patients; however, the functional outcome of restorative proctocolectomy in obese patients is not significantly different than in non-obese patients.

Wound healing in nude mice: a study on the regulatory role of lymphocytes in fibroplasia.

In order to understand the role of T cells in postinjury fibroplasia, we have studied wound healing in congenitally athymic nude mice that lack a normally developed T cell system. Healing of incisional wounds, as assessed by wound breaking strength, was significantly stronger in nude mice compared with normal thymus-bearing animals. This was accompanied by a marked increase in the amount of reparative collagen synthesized at the wound site, as assessed by the hydroxyproline content of subcutaneously implanted sponges. Because nude mice have some extrathymic T cell maturation, we used an anti-Thy-1.2 (30H12) monoclonal antibody to selectively deplete T cells in vivo. Although such treatments impaired wound healing in normal mice, they had no effect on any wound healing parameter in nude mice. In a separate experiment, T cell reconstitution of nude mice, sufficient to significantly enhance in vivo delayed hypersensitivity responses, led to a decrease in both wound breaking strength and hydroxyproline deposition in subcutaneously implanted polyvinyl sponges. The data suggest that T cells play a dual role in wound healing: an early stimulatory role on macrophages, endothelial cells, and fibroblasts, and a late counterregulatory role, which may be responsible for the orderly completion of wound repair.

Inhibition of wound repair by thymic hormones.

To further define the role of the thymus in wound healing, we studied the effects of two thymic hormones on fibroplasia in normal euthymic and in nude athymic mice. Groups of 10 mice underwent a 2.5 cm dorsal skin incision with subcutaneous placement of polyvinyl alcohol sponges. Starting on the day of wounding, the following daily injections were given: (1) thymopentin (TP5), an active synthetic pentapeptide of thymopoietin, a naturally occurring thymic hormone (1 microgram/day/IM); (2) thymulin or facteur thymique serique (FTS), a naturally occurring circulating thymic hormone (0.2 microgram/day/IM); (3) control saline solution (0.1 ml/day/IM). All mice were killed 4 weeks after wounding, and wound breaking strength and hydroxyproline content of the sponge granulomas were measured. The results show that both thymic hormones impaired wound breaking strength and reparative collagen synthesis in normal and athymic mice. The magnitude of the wound healing impairment induced by the two hormones was equal in the thymus-bearing and in the nude mice. The data support previous findings, which suggested that the thymus has an inhibitory effect on wound healing.

Quantitative short-term study of anal sphincter function after chemoradiation for rectal cancer.

HYPOTHESIS: Pelvic irradiation adversely affects anal sphincter function after proctectomy with coloanal anastomosis for low rectal and middle rectal (<10 cm from the anal verge) tumors. DESIGN: Case-control study. SETTING: Private, tertiary care referral center. PATIENTS: Patients treated for low rectal adenocarcinoma between January 1, 1994, and October 31, 1999. INTERVENTIONS: Anal manometric data were prospectively collected at the time of initial diagnosis and before ileostomy closure. MAIN OUTCOME MEASURES: Mean and maximum resting pressures (RPs) and squeeze pressures, threshold volume for sensation, and maximal tolerable volume. RESULTS: Twenty-three patients in the surgery group and 19 in the chemoradiotherapy group were considered for analysis; 15 patients had preoperative radiotherapy and 4 had postoperative radiotherapy. At the time of ileostomy closure, RPs were significantly lower in the chemoradiotherapy group than in the surgery group (32.7 +/- 17 vs 45.3 +/- 18 mm Hg; P =.03). Squeeze pressures were not significantly different between the surgery and chemoradiotherapy groups (108.7 +/- 56.7 vs 102.0 +/- 52.6 mm Hg; P =.69). The ratios of postresection to preresection RPs were also significantly lower in the chemoradiotherapy group (0.49 +/- 0.29) than in the surgery group (0.76 +/- 0.22) (P =.005). Eight to 12 weeks after proctectomy with coloanal anastomosis, a 24% decrease in RP was noted in the surgery group. The addition of adjuvant pelvic irradiation decreased RP by another 27%. CONCLUSION: Adequate shielding of the anal sphincter should be performed for low rectal cancers whenever a sphincter-preserving procedure is considered.

The use of rectal ultrasound for the correct diagnosis and treatment of rectal villous tumors.

BACKGROUND: One of the difficulties associated with surgery for rectal villous tumors (RVT) is the finding of invasive adenocarcinoma after transanal excision (TAE) and the possible need for more radical procedures or adjuvant therapy. Improved preoperative evaluation may eliminate this dilemma. The aim of our study was to evaluate the role of transrectal ultrasound (TRUS) in establishing the correct diagnosis of RVT. METHODS: All patients with biopsy proven RVT, who were referred for TAE, underwent preoperative TRUS in addition to the routine evaluation. If invasion beyond the submucosa was suspected by TRUS, multiple biopsies were taken before any surgical intervention in order to exclude invasive cancer. If no invasion was noted, biopsies were avoided and a TAE was performed. The final pathology results were compared with both the preoperative diagnosis and TRUS results. RESULTS: Thirty-five patients (19 female, 16 male; mean age 67.5 years, range 36 to 88) were studied. The mean distance of the distal extent of the lesion above the anal verge was 5.8 cm (1.5 to 6). In 27 patients, the tumor was limited to the submucosa (uT0, uT1) on TRUS and, therefore, TAE was performed. In 26 of 27 patients (96%), pathology examination confirmed the presence of RVT without evidence of malignancy. One patient was found to have invasion of the muscularis propria and required postoperative radiation therapy. In 8 patients (23%), TRUS showed extension beyond the submucosa; 3 of these patients had uT2 lesions, 4 had uT3 tumors, and 1 had perirectal nodes. These 8 patients underwent repeated biopsies with the finding of invasive adenocarcinoma in 7. Two patients underwent abdominoperineal resection, 3 had a low anterior resection, and 3 had a TAE. Final pathology confirmed the preoperative diagnosis of invasive adenocarcinoma in 7 patients. In the 1 patient with a uT2 lesion and negative biopsies, the final diagnosis was RVT with no evidence of malignancy. CONCLUSIONS: Preoperative TRUS provides an accurate diagnosis of RVT. In conjunction with TRUS-directed biopsies, directed management of these tumors could be achieved.

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.

Converted laparoscopic colorectal surgery.

BACKGROUND: Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial. METHODS: A comprehensive search of the English-language literature was updated until May 1999. RESULTS: Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001). CONCLUSIONS: In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.

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.

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.

Intraoperative endoscopy in laparoscopic colectomy.

BACKGROUND: The localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy. METHODS: We did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon. RESULTS: Between 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group ( p = 0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications. CONCLUSION: Intraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.

Overcoming Wallstent malposition in the treatment of rectosigmoid obstruction.

In recent years, the use of transanal stenting of malignant colonic strictures for the palliation of obstructive symptoms has increased. Due to the rectosigmoid angle, stenting sigmoid tumors is more troublesome than rectal lesions, but the difficulty may be overcome by using a two-team approach. The radiologist assists the endoscopist with the use of fluoroscopy to ensure proper positioning of both the colonoscope and the stent. The most common complication is stent migration, but stent obstruction and colonic perforation may also occur. We treated a woman suffering from metastatic gastric cancer with peritoneal metastases by creating a 12-cm stricture in the sigmoid colon. Two adjoining Wallstents were required to bridge the obstruction. Following migration of the proximal stent, a third stent was introduced to bridge the previous two stents with satisfactory outcome.

An interesting case of mistaken identity.

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder which can present in patients being evaluated for defecatory disorders or which can present as a primary process often involving hematochezia, rectal pain and tenesmus. Unfortunately the diagnosis of this disorder is often delayed due to misdiagnosis and/or physician unfamiliarity with the condition. We present a 24-year-old female who presented with 6 months of bloody diarrhea and weight loss. She had been receiving treatment for a presumed diagnosis of inflammatory bowel disease (IBD) due to an endoscopic picture of rectal thickening, edema and ulceration and had been on prednisone for 2 months prior to presentation without relief of her symptoms. After further testing including repeat endoscopy with biopsies, defecography and anorectal manometry, the diagnosis of SRUS was made and treatment was changed. Medical management was unsuccessful and she ultimately required surgical intervention. This case highlights the difficulty in diagnosing SRUS due to its resemblance to other gastrointestinal diseases and should serve as a reminder that if a patient is not responding to IBD therapy, another etiology should be considered.