Use of Sodium Hyaluronate/Carboxymethylcellulose Bioresorbable Membrane in Loop Ileostomy Construction Facilitates Stoma Closure.

BACKGROUND: Loop ileostomy is a common adjunct to surgical procedures for low rectal cancers and inflammatory bowel disease. Ileostomy closure through a limited incision can be technically challenging. We hypothesized that placing a sodium hyaluronate/carboxymethylcellulose (SH/CMC) bioresorbable membrane at loop ileostomy creation would decrease stoma closure time without increasing morbidity. METHODS: In a retrospective review at a single institution with 6 board-certified colorectal surgeons, patients with loop ileostomy creation and closure between September 1999 and December 2011 were grouped based on SH/CMC placement at ileostomy creation. Data were abstracted for age, sex, body mass index (BMI), primary diagnosis, length of surgery, staff surgeon, interval between surgeries, and postoperative morbidity. The primary endpoint was the length of the surgery for ileostomy closure. Secondary outcome measures were length of stay, wound infection rate, and other complications. RESULTS: A total of 293 patients were identified. Group 1 (with SH/CMC) included 146 patients, and Group 2 (without SH/CMC) included 147 patients. The groups were matched according to age, sex, BMI, interval between creation and closure, and indication for surgery. The average surgical time for closure was significantly shorter in Group 1 (46.4 minutes ± 2.7) compared to Group 2 (60 minutes ± 2.3) (P=0.0001). We found no difference between the groups in length of stay, wound infection rate, or complication rate. CONCLUSION: The use of SH/CMC in loop ileostomy creation significantly decreases the operative time required for stoma closure with no increase in the complication rate.

Practical issues in the surgical care of the obese patient.

The incidence of obesity has steadily climbed to epidemic proportions in the United States. To provide optimal surgical care for the growing number of obese surgical patients, surgeons and other healthcare personnel must often modify routine procedures and standard treatment protocols. Psychological support of obese patients is an additional factor that frequently must be addressed during the perioperative period.

Variations in perioperative steroid management among surgical subspecialists.

Previously we demonstrated consistency in perioperative steroid dosing among colon and rectal surgeons. To determine whether patterns have changed and if dosing schedules differ across surgical specialties, we evaluated multiple specialties. Questionnaires were mailed to members of the American Society of Colon and Rectal Surgeons (CRS) (n = 1523), American Society of Transplant Surgeons (TS) (n = 988), American Society of General Surgeons (GS) (n = 2750), and American Association of Endocrine Surgeons (ES) (n = 278). Surveys addressed demographic factors and factors in dosing, whether steroids are managed by surgeon alone or in collaboration with colleagues, and the most common taper regimens used. Four hundred fifty surveys were returned. Sixty-four respondents had retired or answered less than 50 per cent; 386 (211CRS, 116GS, 45TS, and 14ES) were available for analysis. The majority managed both perioperative (85.5%) and tapers (77%) themselves; TS and ES were significantly less likely to use other physicians (P < 0.001). The preoperative dose used most frequently was 100 mg hydrocortisone intravenously (76% CRS, 64% GS, 22% TS, and 93% ES). Most CRS (44.5%) and GS (24.1%) taper intravenous steroids over 3 days, whereas TS (33.3%) and ES (50%) return patients to prednisone within 1 to 2 days. Discharge steroid use was inconsistent with CRS (46.4%) tapering prednisone over greater than 21 days, GS (19%) over less than 21 days, and TS (20%) and ES (21.4%) taper over 21 days to preoperative prednisone doses (P < 0.001). In the absence of standard guidelines for perioperative corticosteroid administration, significant variations exist in the regimens used by surgeons in multiple specialties.

Outcomes after transanal repair of rectoceles.

PURPOSE: To determine the outcomes of patients after transanal rectocele repair. METHODS: The Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ-22), a validated instrument to evaluate bowel and urinary symptoms, was completed preoperatively by all patients undergoing transanal rectocele repair and postoperatively at a median interval of 8 months. The BBUSQ-22 was also administered to a control group of 50 asymptomatic female patients. The preoperative and postoperative BBUSQ-22 results for the 9 items pertaining to bowel function were compared to each other and to the responses from the control group. RESULTS: Between April 1, 2001 and December 31, 2003, 88 women underwent transanal rectocele repair. Compared to the control group, patients with rectocele were significantly more symptomatic on all of the questions except the ability to hold bowel movements longer than 5 minutes. A significant improvement was reported postoperatively in all areas except pain with bowel movement and ability to hold bowel movements longer than 5 minutes. When the postoperative responses were compared to the control group, there were no significant differences except for a more frequent need for digital assistance and painful defecation in the surgical group. CONCLUSION: Transanal rectocele repair results in significant improvement in defecation and continence, with postoperative bowel function comparable to control patients in 7 of the 9 areas evaluated.

Implications of negative technetium 99m-labeled red blood cell scintigraphy in patients presenting with lower gastrointestinal bleeding.

BACKGROUND: Lower gastrointestinal (GI) bleeding frequently recurs after negative technetium 99m-labeled red blood cell (RBC) scintigraphy. METHODS: Between July 1, 1999 and July 31, 2005, 84 negative (99m)Tc-labeled RBC scintigrams were obtained for acute lower GI bleeding. Medical records were abstracted for age, gender, prior history of lower GI hemorrhage, length of hospitalization, initial hematocrit (Hct) and Hct nadir, transfusion requirements, cause of bleeding, use of anticoagulants and/or antiplatelet medications, and rebleeding episodes. RESULTS: The overall rate of rebleeding was 27% (n = 23). There were no significant associations between any of the patient variables investigated and rebleeding. CONCLUSIONS: Despite negative (99m)Tc-labeled RBC scintigraphy, more than 25% of patients experience recurrent lower GI bleeding. Patient age, bleeding source, use of anticoagulant/antiplatelet medications, length of stay, admission Hct, Hct nadir, transfusion requirements, and gender are not predictive of the patients who will rebleed.

The role of postoperative surveillance in colorectal cancer.

Postoperative surveillance for recurrent and/or metachronous disease is an important component of the treatment of patients with colorectal cancer. The optimal schedule of follow-up investigations remains controversial. Several randomized trials have suggested a moderate improvement in 5-year survival and earlier detection of cancer recurrence with the implementation of intensive surveillance protocols. Whether these protocols are cost-effective has yet to be determined. Current guidelines from the American Society of Colon and Rectal Surgeons recommend periodic patient follow-up with office visits, carcinoembryonic antigen (CEA) measurement, and endoscopy following potentially curative resection of colorectal cancer.

Rectal prolapse: a 10-year experience.

PURPOSE: To compare perineal to abdominal procedures for rectal prolapse over a 10-year period at a single tertiary care institution. METHODS: Between May 1, 1995, and January 1, 2005, 75 patients underwent surgical intervention for primary rectal prolapse at a tertiary referral center. Surgical techniques included perineal-based repairs (Altemeier and Delorme procedures) and abdominal procedures (open and laparoscopic resection and/or rectopexy). Medical records were abstracted for data pertaining to patient characteristics, signs and symptoms at presentation, surgical procedure, postoperative length of hospitalization, morbidity and mortality, and recurrence of rectal prolapse. RESULTS: Seventy-five patients underwent surgical intervention for rectal prolapse during the study period. The average patient age was 60.8 years. Sixty-two patients (82.7%) underwent perineal-based repair (Altemeier n = 48, Delorme n = 14); eight patients (10.7%) underwent open abdominal procedures (resection and rectopexy n = 4, rectopexy only n = 4); and five patients (6.7%) underwent laparoscopic repair (laparoscopic LAR n = 3, laparoscopic resection and rectopexy n = 2). Average hospitalization was shorter with perineal procedures (2.6 days) than with abdominal procedures (4.8 days) (p < 0.0031). Postoperative complications were observed in 13.3% of cases. With a median follow-up of 39 months (range 6-123 months), there was no mortality for primary repair, a postoperative morbidity occurred in 13% of patients, and the overall rate of recurrent prolapse was 16% (16.1% for perineal-based repairs, 15.4% for abdominal procedures). CONCLUSION: Perineal resections were more common, performed in significantly older patients, and resulted in a shorter hospital stay. Their minimal morbidity and similar recurrence rates make perineal procedures the preferred option.

Evaluation and management of gastrointestinal bleeding.

A logical, reasoned approach is essential to the successful management of gastrointestinal hemorrhage. This article describes the approach used by the staff of the Ochsner Clinic Foundation's Department of Colon and Rectal Surgery to evaluate and manage lower gastrointestinal hemorrhage, along with the evidence and experience that guided its development. Following resuscitation, diagnostic studies localize the presence and source of hemorrhage, while management options (non-operative and operative) control the bleeding.

Surgical hemorrhage, damage control, and the abdominal compartment syndrome.

The morbidity and mortality associated with surgical hemorrhage are considerable, particularly when relaparotomy is necessary. This complication can usually be avoided with comprehensive preoperative patient evaluation and meticulous surgical technique. The damage control sequence is a useful surgical strategy when severe intraoperative coagulopathy or hemodynamic instability is present. Abdominal compartment syndrome is a potentially lethal phenomenon that can occur following laparotomy or large-volume fluid resuscitation, or both. Early recognition and intervention are critical to survival of the patient when this syndrome occurs.