Anal dysplasia as an incidental finding: the importance of specimen evaluation.

AIM: The incidence of anal squamous cell carcinoma (SCC) has increased dramatically in the USA. The squamous intraepithelial lesion has been identified as a precursor lesion to SCC, stratifying the abnormality into low grade or high grade. There have been studies on the prevalence of incidentally found SCC in haemorrhoidectomy specimens, but there are no studies to date on the incidence of dysplasia. The purpose of this study was to establish a baseline incidence of dysplasia that provides helpful information for future epidemiological studies. METHODS: This is a retrospective review of patients who underwent haemorrhoidectomy from 2005 to 2019. Pathology regarding the type of dysplasia, medications, and diagnoses that may predispose to immunosuppression were collected. RESULTS: In all, 810 patients with a mean age of 51.7 (range 20-91) years underwent haemorrhoidectomy. Eighteen (2.2%) of the patients had abnormal pathology (low-grade squamous intraepithelial lesion, 3; high-grade squamous intraepithelial lesion, 12; SCC, 2; adenocarcinoma, 1). Thirty-seven (4.5%) of the entire cohort had some risk factors for immunosuppression: chronic steroid use (nine), human immunodeficiency virus (HIV) (13), biologic medications (six), transplant recipients (two) and immunocompromising diseases (four). Only 4/18 patients had an immunosuppression risk in that all four of these patients were HIV-positive. Surveillance following excision was undertaken for an average of 6 (range 1-12) months, during which time four patients underwent a repeat biopsy. DISCUSSION: Anal dysplasia found in an otherwise asymptomatic population has a prevalence of 2.2%. This finding supports the routine examination of benign anorectal specimens undergoing microscopic examination. Interestingly, the majority of the patients identified had no immunosuppressant risk factors.

Short-term outcome of infliximab and other medications on patients with inflammatory bowel disease undergoing ileostomy reversal.

AIM: We evaluated the impact of immunosuppressive drugs on the short-term outcome following loop ileostomy closure in patients with inflammatory bowel disease. METHOD: Data on 249 patients with inflammatory bowel disease, who underwent loop ileostomy closure from 2001 to 2008, were retrospectively reviewed from a prospectively maintained database. Patients were distributed among groups according to the inflammatory bowel disease drugs used. Comorbidity, diagnosis, intra-operative and postoperative morbidity and length of stay data were analysed. Patients in group (INF) were receiving infliximab with or without other immunosuppressive agents (28), patients in group (S) were receiving only steroids (72) and those, in group III (S&I) were on steroids plus immunosuppressive agents, other than infliximab (35). Patients in group (ND) had not received any immunosuppressive agents for 2 months and served as the control group (114). RESULTS: Postoperative complication rates (wound infection, hernia, obstruction, intra-abdominal abscess, leakage, enterocutaneous fistula and sepsis) occured in 4.0, 12.0, 14 and 17.0% of patients in the four groups (P > 0.05). Reoperation was needed in 3.0% (2) of patients in group S, 6.0% (2) in S&I and 3.0% (3) in C groups, and the mean hospital stay was 4.6 (± 2.1), 5.6 (± 4.6), 5.2 (± 4.7) and 5.2 (± 6) days in groups INF, S, S&I and ND, respectively. There was no mortality. CONCLUSION: There were no significantly increased postoperative complications after ileostomy closure in patients who received infliximab or other immunosuppressive medications compared with patients who did not.

Imbrication of the external anal sphincter may yield similar functional results as overlapping repair in selected patients.

OBJECTIVE: Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates. METHOD: Patients who had external anal sphincter repair and follow up of at least 3 months were studied. Fecal incontinence was measured using the validated Wexner fecal Incontinence Scoring system (0 = perfect continence, 20 = complete incontinence); postoperative scores 0-10 were interpreted as successful, and scores of 11-20 as failures. RESULTS: A total of 131 females who had anal sphincter repair between 1988 and 2000 were analysed. One hundred and twenty-one patients had overlapping external anal sphincter repair (group I), and 10 had external anal sphincter imbrication (group II). Indications for external anal sphincter imbrication were attenuation of the external anal sphincter without overt defect (n = 5), partial disruption of external anal sphincter with muscle fibres bridging the scar (n = 2), thick bulk of scar between the muscle edges (n = 2), and wide lateral retraction of the muscle edges (n = 1). There were no statistically significant differences between the groups relative to preoperative incontinence score (16.5 vs 16.5, P = 0.99), pudendal nerve terminal motor latency assessment (left 9.6%vs 0.0%, P = 0.19; right 13.4%vs 11.1%, P = 0.84), and extent of electromyography pathology (61%vs 47%, P = 0.30). The patients in group I were younger than those in group II (mean age 50.8 years vs. 61.7 years, respectively; P = 0.052) and the length of follow-up was significantly longer (32.3 months vs 14.3 months, respectively; P < 0.0001). Both procedures had similar success rates (59.5%vs 60%; P = 0.98). CONCLUSION: Imbrication of the external anal sphincter may yield similar results as overlapping external anal sphincter repair in patients with incomplete external anal sphincter disruptions, external anal sphincter attenuation, and in patients presenting with wide lateral retraction of the muscle edges.

Faecal incontinence in male patients.

OBJECTIVE: Data concerning faecal incontinence (FI) in men are lacking. The aim of this study was to evaluate the historical aetiology and contrast aetiologies in younger and older men suffering from FI. METHOD: After institutional review board approval, a retrospective chart review was undertaken of all patients with FI seen between 1999 and 2005. The data of male patients was further analysed to assess the impact of age and historical aetiology on FI. RESULTS: A total of 404 males were included, 203 patients were <70 years of age (group A) and 201 patients were >or=70 years of age (group B). The most common prior diagnosis in group A was perianal sepsis in 23 (11.3%) patients and symptomatic haemorrhoids in 20 (9.9%) patients; in group B it was prostate cancer in 57 (28.4%) patients, symptomatic haemorrhoids in 31 (15.4%) patients and neurological diseases in 18 (9%) patients. The most common prior procedure in group A was restorative proctectomy/proctocolectomy in 32 (15.8%) patients, fistulotomy or haemorrhoidectomy in 21 (10.3%) and 19 (9.4%) patients respectively. In group B, radiation therapy for prostate cancer was utilized in 48 (23.9%) patients and haemorrhoidectomy in 29 (14.4%) patients. Comparing group A and group B relative to diagnosis - perianal sepsis, perineal trauma, congenital disorders, HIV infection and anal cancer were more common in group A, whereas prostate cancer, neurological diseases and colon cancer were significantly more common in group B. CONCLUSION: Prostate cancer, symptomatic haemorrhoids, perianal sepsis, rectal cancer and a history of restorative rectal resection were common associations with FI in men. The aetiologies for FI in men vary with age.

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.

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.

Functional results of the double-stapled ileoanal reservoir.

BACKGROUND: The preferred method for creation of an ileoanal reservoir is still controversial. We prospectively studied the functional and physiologic outcome of our patients who underwent a double-stapled ileoanal reservoir (DSIAR). STUDY DESIGN: All consecutive patients who underwent restorative proctocolectomy with a DSIAR between 1988 and 1993 were evaluated. Functional results were assessed by questionnaires and anal manometry preoperatively and two, 12, and 24 months postoperatively. RESULTS: One hundred forty patients (90 males and 50 females) with a mean age of 40.7 (range, 12 to 71) years were evaluated. Of these, 107 patients (77 percent) had ulcerative colitis, 21 (15 percent) had familial adenomatous polyposis, six (4 percent) had indeterminate colitis, and six (4 percent) had a post-operative diagnosis of Crohn's disease. One hundred twenty-four (95 percent) of the 131 patients with closed stomas were available for functional and manometric evaluation at a mean follow-up period of 24 months. A 32 percent decline in the mean resting pressure (from 71.3 +/- 4 to 48.2 +/- 3.4 mm Hg) occurred early after DSIAR (p < 0.001) with partial recovery by 24 months. The maximal internal sphincter resting pressure showed a 39 percent decline (from 90.8 +/- 4.9 to 55.3 +/- 5.7 mm Hg, p < 0.005) with recovery after 12 months. There were no significant changes in the length of the high-pressure zone or mean or maximal squeeze pressures. A mean of 5.4 (two to 13) bowel movements occurred during the day and a mean of 1.2 (zero to four) occurred at night. Perfect or almost perfect continence was reported during the day and night, respectively, by 95 and 92 percent of the patients. Overall perioperative complications occurred in 30 patients (21 percent) including septic complications in eight (6 percent), and pouchitis in eight (6 percent). There was one postoperative death (0.7 percent). CONCLUSIONS: Double-stapled ileoanal reservoir is associated with good subjective functional and objective physiologic results and has acceptable rates of morbidity and mortality.

Electrolyte profiles within the ileoanal pouch: measurement by an in vivo equilibrium dialysis technique.

BACKGROUND: Patients with an ileoanal pouch have high rates of fluid and electrolyte loss. These improve with pouch adaptation. There is limited information concerning secretion and absorption in the stable ileoanal pouch. A new method to measure and characterize electrolytes in the ileoanal pouch is described. METHODS: Following an in vitro study, nine patients with a stable ileoanal pouch had consecutive placement of dialysis bags consisting of a semi-permeable membrane containing 5 ml of 10% dextran in normal saline into the ileoanal pouch. These were left in place for 15, 30, 60, and 120 min. After determining that 60 min was the optimal timing for measurement of electrolyte concentrations, 12 normal volunteers underwent a similar in vivo dialysis study with dialysis bags withdrawn at 60 min. Sodium, chloride, potassium, phosphorus, calcium and magnesium concentrations in the dialysis bags were compared between the two groups. RESULTS: In the in vitro and in vivo studies, the measured electrolytes reached equilibrium within 60 min. Statistically significant differences between sodium concentrations (160.9 +/- 30.2 vs. 116.8 +/- 13.8 mmol/l, respectively) and phosphorus concentrations (6.8 +/- 5.2 vs. 1.8 +/- 0.7 mg/dl, respectively) at 60 min in ileoanal pouch patients and volunteers were found (p<0.001). There were no statistical differences in the other measured electrolytes between the two groups. CONCLUSION: An in vivo dialysis technique is described for measuring electrolyte concentrations within the ileoanal pouch. Differences in sodium and phosphate concentrations may reflect incomplete adaptation of the ileoanal pouch, and are a potential explanation for increased stool frequency in these patients.

Principles of surgical resection. Influence of surgical technique on treatment outcome.

In the absence of curative medical therapy, surgical resection remains the cornerstone of treatment for patients with colorectal carcinoma. A thorough knowledge of colon and rectal anatomy is crucial for the formulation of an effective operative strategy. There are certain technical factors under the control of the surgeon that may have prognostic significance for the patient. These include the length of the distal margin of resection, the use of intraluminal cytotoxic solutions to reduce the viability of exfoliated cancer cells, and the technique of colon anastomosis. Curative resections should include removal of the lymphatic drainage of the tumor-bearing segment of colon. When there is adjacent organ invasion by the colonic primary, en block resection of the entire tumor mass with adequate margins is the procedure of choice. Prophylactic oophorectomy in women with colon carcinoma remains controversial. The effects of perioperative transfusion on tumor behavior remain unclear. Blood transfusions should be administered only when there is a specific medical necessity.

Variability in serotonin and enterochromaffin cells in patients with colonic inertia and idiopathic diarrhoea as compared to normal controls.

AIM: To evaluate differences in distribution, density and staining intensity of enterochromaffin cells (EC) and serotonin cells (SC) in the colonic mucosa of patients with colonic inertia (CI), idiopathic diarrhoea (ID) and a control group. METHODS: Three groups were studied: 19 patients' colons after subtotal colectomy for CI, and 17 patients' biopsies for diarrhoea (>3 bowel movements/day) with histological findings of normal mucosa (excluding microscopic, eosinophillic and collagenous colitis). The third group included 15 patients who underwent colonoscopy and biopsy for indications other than constipation, inflammatory bowel disease, diarrhoea or neoplasm (control group). Specimen blocks were obtained in each case from the right and left colon. Immunohistochemical staining for EC and SC were done on 4 micro m sections from Hollandes fixed, paraffin embedded tissues with primary rabbit antibody against chromagranin A or serotonin, and biotynylated secondary antibody and enzyme labelled streptavidin. RESULTS: The number of EC in the mucosa of the left colon in patients with CI (16.8 +/- 10.2) and ID (19.9 +/- 9.7) were significantly higher than they were on the right side (CI: 9.4 +/- 6.0, ID: 12.1 +/- 5.3). However, there were no significant differences between the left and right sides in the control group (L: 10.3 +/- 5.3; R: 13.4 +/- 7.6). Although the quantity of EC in the left colon in both patients with CI (P < 0.05) and ID (P < 0.01) were significantly higher than in the controls, there was no significant difference between CI and ID. In both the right and left colon, the percentage of EC with low positive density was significantly higher (P < 0.01) while those cells with moderate or low staining intensity were significantly lower in patients with CI than in either patients with ID or control group. In patients with CI, the quantity of SC in the mucosa of the left colon (12.1 +/- 6.4) was higher than in the right (CI: 7.9 +/- 3.6; control 4.6 +/- 3.3; ID 4.6 +/- 2.9) (P = 0.0057). In contrast there was no significant difference in SC in either the ID or control groups. The quantity of SC in both sides of the colon was significantly higher both in patients with CI as compared to the control group (P < 0.01) and patients with CI vs. patients with ID (L = P < 0.01; R = P < 0.05). There was a significantly positive correlation between the numbers of EC and SC in patients with CI (L: r = 0.5425, P < 0.05; R: r = 0.745, P < 0.01). CONCLUSION: In patients with CI, EC increases possibly due to an increase in SC. Conversely, in patients with ID, the EC increase results from peptides other than SC. Our results suggest that different aetiological factors contribute to ID and CI.

Overlapping sphincteroplasty: does preservation of the scar influence immediate outcome?

BACKGROUND: The importance of the overlapping scar in an anterior sphincteroplasty is often emphasized. The aim of this study was to identify the tissue type used in overlapping sphincter repair based upon ultrasound images, and to correlate these results with the immediate clinical outcome. METHODS: Data were collected prospectively on all patients with faecal incontinence who underwent anterior overlapping sphincteroplasty between June 1998 and May 1999. Continence was assessed by a standardized incontinence score ranging from 0 to 20. Pre-operative ultrasound images were compared to intraoperative ultrasound findings for each patient. In each case the surgeon performed an overlap of what was grossly felt to represent scar after which a single blinded observer performed intraoperative ultrasound. The degree of overlap was measured and classified as hyperechoic over hyperechoic (muscle over muscle; Type 1), hyperechoic over or under hypoechoic (muscle over or under scar; Type 2), hypoechoic over hypoechoic (scar over scar; Type 3). The patient follow-up included incontinence score that was obtained by telephone interview; suboptimal outcome was considered as an incontinence score >/= 6. Statistical analysis was performed using the Mann-Whitney test and Wilcoxon matched-pairs test. RESULTS: Fourteen female patients with a mean age of 51.6 (range 28-79) years were evaluated. The mean pre-operative incontinence score was 17.1 (range 7-20) and 13 of the 14 (93%) patients had an incontinence score >/= 15. All pre-operative ultrasound images were hypoechoic which correlated with the surgeon's intraoperative findings of scar. The operative appearance included two Type 1, four Type 2, and eight Type 3 images. Larger pre-operative ultrasound image defects were statistically significantly related to intraoperative Type 3 ultrasound images. At a mean follow up of 7.5 (range 2-16) months the mean postoperative incontinence score was 4.5 (range 0-12). In patients with Type 1 and Type 2 images, the mean postoperative score was 8.6 (range 4-12) whereas in patients with Type 3 it was 1.3 (range 0-5) (P < 0.003); 7 of the 8 patients in Type 3 (87.5%) had an incontinence score

Current attitudes in laparoscopic colorectal surgery.

BACKGROUND: In this study, we set out to examine the current attitudes among surgeons toward laparoscopic colorectal surgery (LCS). METHODS: A total of 3628 questionnaires were sent to all North American members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS); 40% of the members of each society responded (B15 respondents). RESULTS: Currently, 85% of the respondents perform laparoscopic surgery; LCS was performed by 48% of the respondents in 21% of their patients. Although 35% of the members of SAGES have increased the number of laparoscopic colorectal operations they perform in the last 3 years, only 26% of ASCRS members did so. Our findings showed that 74% of the surgeons who perform LCS do so for diverticular disease, 68% for colonic polyps, 61% for villous adenoma, and 36% for ileal Crohn's disease. However, only 15% operate for the cure of carcinoma of any stage (16% of SAGES members and 11% of ASCRS members), whereas 8.5% and 7% operate for the cure of all upper and lower rectal carcinomas, respectively. Thirty-six percent of the surgeons who perform LCS for cancer have done between one and 10 curative resections, 8% have done 11-20 procedures, and 14% have done >20 procedures. There were 80 cases of port site recurrence reported by 4.4% of surgeons. Although 56% of the respondents would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 9% would do so for a distal-third rectal carcinoma (12% of SAGES and 5% of ASCRS respondents). CONCLUSIONS: The overall percentage of respondents performing LCS has decreased over the last 3 years; moreover, surgeons are more hesitant to perform laparoscopic surgery for the cure of colonic cancer. Due to the overall low response rate, the fact that 4.4% of those surgeons who did respond have seen port site recurrences does not allow any conclusions to be drawn about the prevalence of this problem.

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.

Long-term outcome and health-related quality of life after laparoscopic and open colectomy for benign disease.

BACKGROUND: The benefits of laparoscopic colectomy (LC) vs open colectomy (OC) for the treatment of benign disease have not yet been clearly demonstrated with regard to long-term consequences and health-related quality of life (HRQL). The aim of this study was to compare LC and OC in terms of outcome and HRQL and to determine whether a generic nonspecific instrument for HRQL assessment is valid in postoperative follow-up. METHODS: Forty-nine patients who underwent LC for elective right hemicolectomy (RH) or sigmoid resection (SR) for benign polyps or uncomplicated diverticular disease between 1992 and 2000 were evaluated and compared to 50 controls treated by OC in the same period. All patients were evaluated by postal questionnaire to determine recurrence rates and surgery-related complications. HRQL was assessed by the SF-36 Physical and Mental Component Summary Score (PCS, MCS) and by the SF-36 Health Survey, which measures eight different health-quality domains, including physical and social functioning (PF, SF), general health perception (GH), physical and emotional role limitations (RP, RE), body pain (BP), vitality (VT), and mental health (MH). RESULTS: The LC and OC patients were similar in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and diagnosis. There were significant differences between the two groups in resection type (26 RH:23 SR in LC vs 16 RH:34 SR in OC, p = 0.03) and length of follow-up (median, 39 and 53.5 months, respectively, p = 0.04), but neither parameter was predictive of the main SF-36 scores (PCS and MCS). There were no differences between the groups in recurrence rates (8% in LC vs 11% in OC) or surgery-related complications, including incisional hernias (16.3% in LC vs 17% in OC) and small bowel obstructions (2% in LC vs 10.4% in OC). None of the eight SF-36 Health Survey domains or the PCS or MCS scores showed significant differences between LC and OC patients in HRQL. However, occurrence of hernia after surgery was predictive of lower SF-36 scores, specifically in PF (p = 0.047), GH (p = 0.045), SF (p = 0.047), MH (p = 0.041), and MCS (p = 0.037). In addition, small bowel obstruction was significantly associated with lower scores in BP (p = 0.008), GH (p = 0.008), SF (p = 0.013), RE (p = 0.026), MH (p = 0.003), and MCS (p = 0.003). CONCLUSION: LC was not different from OC for selected indications that measure long-term outcome and HRQL. SF-36 appears to be an appropriate instrument to measure postoperative HRQL, showing responsiveness to changes in objective outcome measures.

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.

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.

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.

Is obesity a high-risk factor for laparoscopic colorectal surgery?

BACKGROUND: The aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures. METHODS: All 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality. RESULTS: Thirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p = 0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% versus 24% in the nonobese group (p <0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs. 7.6% (p <0.01) and 12.9 vs 3.1%. (p = 0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p = 0.02). CONCLUSION: Laparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.

Peutz-Jeghers syndrome. A call for intraoperative enteroscopy.

Peutz-Jeghers syndrome is a disease manifested by a combination of mucocutaneous pigmentation and gastrointestinal (GI) polyposis. The major morbidity results from intussusception, obstruction, and bleeding. Standard surgical management has been to perform enterotomies at the site of palpable polyps. A method of treating Peutz-Jeghers syndrome surgically with combined intraoperative enteroscopy is presented. The patient had eight large polyps that required three enterotomies for removal. Only three of the polyps were palpable. Two intussusceptions were reduced. The advantages of intraoperative enteroscopy are that 1) it provides accurate assessment of the extent of the disease, 2) smaller polyps can be treated endoscopically, preventing enterotomies, and 3) the endoscopist can direct the surgeon to the appropriate enterotomy sites. A combined surgical and endoscopic approach for the management of Peutz-Jeghers is successful. It more accurately removes the cause of the major morbidity associated with the disease and may allow the patient a longer interval between laparotomies.