Risk Factors that Predict Recurrent Clostridium difficile Infections in Surgical Patients.

Clostridium difficile (C. difficile) infection (CDI) is a serious problem mostly studied during patients' index infections. The aim of this study is to define the incidence of primary and recurrent postoperative (postop) CDI in a single institution's entire surgical population and to identify risk factors that influence disease recurrence. Using electronic medical records from 2002 to 2012, charts were reviewed from all patients with laboratory-proven (enzyme-linked immunosorbent assay or polymerase chain reaction methods) C. difficile-positive stool samples. Index postop CDI was defined as a positive C. difficile assay (CDA) within 30 days of surgery and recurrence was defined as a positive CDA within 30 days of any surgery in a patient with a previously documented positive CDA. Patient demographics, surgical diagnoses, and laboratory data were recorded. Approximately 342,000 surgeries were performed in the study period with a 0.6 per cent (2188 patients) incidence of index postop CDI. Patients undergoing musculoskeletal surgery had the highest recurrent CDI rate [odds ratio (OR) 3.09 (1.47-6.49), P = 0.003]. Use of any steroid (OR 2.45 [1.43-4.20], P = 0.002) or other immunosuppressant (OR 2.64 [1.09-6.38], P = 0.011) within six months of surgery was associated with an increased risk of the development of a recurrent CDI. Across surgical specialties at our institution, postop index CDI is low and patients have about a 5-fold increased risk for developing recurrent CDI. Patients undergoing musculoskeletal surgery are at greater risk for CDI recurrence and younger age, use of steroids and immune modulators, and surgery by organ system are independent risk factors for a recurrent CDI.

Outcomes associated with resident involvement in laparoscopic colorectal surgery suggest a need for earlier and more intensive resident training.

PURPOSE: The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1-2, 3-5, ≥6) and Attending Only group. RESULTS: A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 ± 66.7 vs. 140.7 ± 67.2 minutes, P < .001) and length of hospital stay (5.8 ± 5.4 vs. 5.6 ± 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time (P < .001), and PGY ≥ 6 was associated with an increased length of stay (P < .001). CONCLUSION: Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.

Adjusting glucose-stimulated insulin secretion for adipose insulin resistance: an index of ß-cell function in obese adults.

OBJECTIVE: The hyperbolic relationship between insulin secretion and sensitivity has been used to assess in vivo ß-cell function (i.e., the disposition index). The disposition index emphasizes the importance of taking into account both skeletal muscle and hepatic insulin resistance to depict insulin secretion. However, we propose that adipose tissue insulin resistance also needs to be accounted for when characterizing glucose-stimulated insulin secretion (GSIS) because elevated plasma free fatty acids (FFAs) impair ß-cell function. RESEARCH DESIGN AND METHODS: To characterize the adipose disposition index, we used [1-(14)C] palmitate infusion to determine basal FFA turnover rate/adipose insulin resistance and an oral glucose tolerance test to characterize the first (i.e., 0-30 min) and second phase (i.e., 60-120 min) of GSIS. We validated a simplified version of the tracer infusion calculation as the product of (1/plasma FFA concentration × plasma insulin concentration) × GSIS in 44 obese insulin-resistant subjects. RESULTS: The plasma FFA and palmitate tracer infusion calculations of the first- and second-phase disposition index were strongly correlated (r = 0.86, P < 0.000001 and r = 0.89, P < 0.000001, respectively). The first- and second-phase adipose disposition index derived from plasma FFA also was tightly associated with fasting hyperglycemia (r = -0.87, P < 0.00001 and r = -0.89, P < 0.00001, respectively) and 2-h glucose concentrations (r = -0.86, P < 0.00001 and r = -0.90, P < 0.00001). CONCLUSIONS: Adjusting GSIS for adipose insulin resistance provides an index of ß-cell function in obese subjects across the glucose spectrum. Plasma FFA-derived calculations of ß-cell function may provide additional insight into the role of adipose tissue in glucose regulation.

Statin therapy is associated with improved pathologic response to neoadjuvant chemoradiation in rectal cancer.

BACKGROUND: Achieving a pathologic complete response to neoadjuvant chemoradiation improves prognosis in rectal cancer. Statin therapy has been shown to enhance the impact of treatment in several malignancies, but little is known regarding the impact on rectal cancer response to neoadjuvant chemoradiation. OBJECTIVE: The purpose of this study was to determine whether statin use during neoadjuvant chemoradiation improves pathologic response in rectal cancer. DESIGN: This was a retrospective cohort study based on data from a prospectively maintained colorectal cancer database. The 2 cohorts were defined by statin use during neoadjuvant chemoradiation. SETTING: This study was performed at a single tertiary referral center. PATIENTS: Four hundred seven patients with primary rectal adenocarcinoma who underwent neoadjuvant therapy then proctectomy between 2000 and 2012 were included. Ninety-nine patients (24.3%) took a statin throughout the entire course of neoadjuvant therapy. MAIN OUTCOME MEASURES: The primary outcome measure was pathologic response to neoadjuvant chemoradiotherapy as defined by the American Joint Committee on Cancer tumor regression grading system, grades 0 to 3. RESULTS: Patients in the statin cohort had a lower median regression grade (1 vs 2, p = 0.01) and were more likely to have a better response (grades 0-1 vs 2-3) than those not taking a statin (65.7% vs 48.7%, p = 0.004). Statin use remained a significant predictor of an American Joint Committee on Cancer grade 0 to 1 (OR, 2.25; 95% CI, 1.33-3.82) in multivariate analyses. Although statin use itself did not significantly improve oncologic outcomes, an American Joint Committee on Cancer grade 0 to 1 response was associated with statistically significant improvements in overall survival, disease-free survival, cancer-specific mortality, and local recurrence. LIMITATIONS: This was a retrospective study and subject to nonrandomization of patients and incorporated patients on variable statin agents and doses. CONCLUSIONS: Statin therapy is associated with an improved response of rectal cancer to neoadjuvant chemoradiation. These data provide the foundation for a prospective clinical trial.

The clinical significance of an elevated postoperative glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control?

OBJECTIVES: To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery. METHODS: Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center. Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and/or based on HbA1C levels. The association between any elevated postoperative random glucose value (hyperglycemia: >125 mg/dL) and level of elevation (>125 mg/dL or >200 mg/dL) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed. RESULTS: Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7% patients experienced hyperglycemia. Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity (blood loss). Hyperglycemia was associated with infectious and noninfectious complications and mortality, the rates of these complications increasing parallel to the degree of hyperglycemia. Hyperglycemia was independently associated with septic complications (P = 0.024). CONCLUSIONS: Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients. Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality; this risk is related to the degree of glucose elevation. These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients.

Quantification of risk for early unplanned readmission after rectal resection: a single-center study.

BACKGROUND: Several factors predictive of readmission after colorectal surgery have been identified. Although often grouped together in readmission studies, colon and rectal resections differ in many ways. The aim of this study was to identify factors associated with readmission after rectal resection. STUDY DESIGN: We performed a retrospective, single-center cohort study of 565 patients who underwent rectal resections at a tertiary referral center in 2010 and 2011. The main outcomes measure was readmission within 30 days. Univariate comparison between readmitted and nonreadmitted patients was followed by a stepwise logistic regression to identify independent risk factors for readmission. RESULTS: There were 105 patients (18.6%) readmitted. Indication (inflammatory bowel disease [IBD], p = 0.008), type of operation (pelvic pouch surgery, p = 0.02), use of laparoscopy (readmission 27.8% vs 14%, p < 0.001), and length of operation (p < 0.001) were associated with a higher readmission rate on univariate analysis. Neither preoperative chemoradiation (p = 0.89) nor American Society of Anesthesiologists class (p = 0.09) was associated with readmission. Logistic regression showed use of laparoscopy (odds ratio [OR] 1.94, 95% CI 1.23 to 3.07), initial diagnosis of IBD (OR 1.84, 95% CI 1.17 to 2.93), and length of operation (OR 1.09, 95% CI 1.03 to 1.16 per 30 minutes) to be independent risk factors. Risks of readmission were 6.7%, 13.4%, 27.4%, and 27.4% with 0, 1, 2, or 3 positive risk factors, respectively. CONCLUSIONS: Readmission after rectal resection is associated with the indication for surgery and the operative technique used. Optimization of factors related to the underlying pathology and careful appraisal of the operative technique may result in decreased readmission after proctectomy.

A novel nomogram accurately quantifies the risk of mortality in elderly patients undergoing colorectal surgery.

OBJECTIVE: The ability to accurately predict postoperative mortality is expected to improve preoperative decisions for elderly patients considered for colorectal surgery. METHODS: Patients undergoing colorectal surgery were identified from the National Surgical Quality Improvement Program database (2005-2007) and stratified as elderly (>70 years) and nonelderly (<70 years). Univariate analysis of preoperative risk factors and 30-day mortality and morbidity were analyzed on 70% of the population. A nomogram for mortality was created and tested on the remaining 30%. RESULTS: Of 30,900 colorectal cases, 10,750 were elderly (>70 years). Mortality increased steadily with age (0.5% every 5 years) and at a faster rate (1.2% every 5 years) after 70 years, which defined "elderly" in this study. Elderly (mean age: 78.4 years) and nonelderly patients (52.8 years) had mortality of 7.6% versus 2.0% and a morbidity of 32.8% versus 25.7%, respectively. Elderly patients had greater preoperative comorbidities including chronic obstructive pulmonary disease (10.5% vs 3.8%), diabetes (18.7% vs 11.1%), and renal insufficiency (1.7% vs 1.3%). A multivariate model for 30-day mortality and nomogram were created. Increasing age was associated with mortality [age >70 years: odds ratio (OR) = 2.0 (95% confidence interval (CI): 1.7-2.4); >85 years: OR = 4.3 (95% CI: 3.3-5.5)]. The nomogram accurately predicted mortality, including very high-risk (>50% mortality) with a concordant index for this model of 0.89. CONCLUSIONS: Colorectal surgery in elderly patients is associated with significantly higher mortality. This novel nomogram that predicts postoperative mortality may facilitate preoperative treatment decisions.

Effect of obesity on B-type natriuretic peptide levels in patients with pulmonary arterial hypertension.

Brain natriuretic peptide (BNP) levels are lower in obese patients with left ventricular failure than in their comparably ill, leaner counterparts. The effect of obesity on BNP in patients with pulmonary arterial hypertension (PAH) is unknown. We reviewed our prospective PAH registry data collected from November 2001 to December 2007 for patients undergoing right heart catheterization who met the criteria for PAH and had the BNP level and body mass index determined at baseline. The median BNP level for the lean, overweight, and obese patients was 285 pg/ml (interquartile range 131 to 548), 315 pg/ml (interquartile range 88 to 531), and 117 pg/ml (interquartile range 58 to 270), respectively (p = 0.029). A greater body mass index was associated with a lower BNP level, adjusted for age, gender, New York Heart Association functional class, hypertension, coronary artery disease, and mean right atrial and pulmonary arterial pressures (p <0.001). No statistically significant differences were found among the groups in age, race, medical co-morbidities, underlying etiology of PAH, use of vasoactive medications, New York Heart Association functional class, echocardiographic parameters, or pulmonary function. Obese patients had greater right atrial and pulmonary artery pressures. Increased BNP was associated with worse survival in the lean and overweight patients only. In conclusion, the BNP levels are attenuated in obese patients with PAH despite similar or worse hemodynamics or functional class compared to lean or overweight patients and should therefore be interpreted with caution.

A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score.

BACKGROUND/OBJECTIVE: Postoperative ileus (POI) after colorectal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra-, and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic partial colectomy. METHODS: Patients operated between 2004 and 2008 were retrospectively identified from a prospectively maintained database, and clinical, metabolic, and pharmacologic data were obtained. Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Associations between likelihood of POI and study variables were assessed univariably by using χ tests, Fisher exact tests, and logistic regression models. A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors. RESULTS: A total of 413 patients (mean age, 58 years; 53.5% women) were included, and 42 (10.2%) of them developed POI. Preoperative albumin, postoperative deep-vein thrombosis, and electrolyte levels were associated with POI. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis, which allowed the creation of a predictive score. Patients with a score of 2 or higher had an 18.3% risk of POI (P < 0.001). CONCLUSION: Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors. The likelihood of POI can be predicted by using a preoperative scoring system. Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients.

Individual surgeon, pathologist, and other factors affecting lymph node harvest in stage II colon carcinoma. is a minimum of 12 examined lymph nodes sufficient?

BACKGROUND: Insufficient lymph node harvest in presumed stage II colon carcinomas can result in understaging and worsened cancer outcomes. The purpose of this study was to evaluate factors affecting the number of lymph node examined, their corresponding impact on cancer outcomes, and the optimal number of examined nodes with reference to the standard of 12. MATERIALS AND METHODS: We evaluated all patients undergoing surgery alone for stage II colon cancer included in our colorectal cancer database since 1976. RESULTS: A total of 901 patients were included. Mean follow-up exceeded 8 years. The individual pathologist had no statistically significant association with the number of lymph nodes examined. Harvest of at least 12 nodes was related to surgery after 1991 (85% vs 69%, P < 0.001), right vs left colon carcinomas (85% vs 72%, P < 0.001), individual surgeon (P = 0.018), and length of specimen at different cutoffs of at least 30, 25, and 20 cm (P < 0.001). Increasing age was associated with fewer examined lymph nodes (Spearman correlation = -0.22, P < 0.001). Fewer than 12 nodes and T4N0 staging independently affected overall survival (P = 0.003 and P = 0.022, respectively), disease-free survival (P = 0.010 and P = 0.09, respectively), disease-specific mortality (P = 0.009 and P < 0.001, respectively), and overall recurrence (P = 0.13 and P = 0.023, respectively). A minimal number of more than 12 examined nodes had no significant effect on cancer outcomes. CONCLUSIONS: A number of factors influenced lymph node harvest in stage II colon cancer. However, lymph node assessment of at least 12 nodes was the only modifiable factor optimizing cancer outcomes.

Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse.

BACKGROUND: We can divide surgery for rectal prolapse into two broad categories: abdominal and perineal. However, few studies compare the long-term outcomes and quality of life among operations for full-thickness rectal prolapse. The purpose of this study was to compare abdominal (AO) versus perineal (PO) procedures for the treatment of full-thickness rectal prolapse regarding recurrence rate, incontinence, constipation, and quality of life. METHODS: Records of 177 operations from 1995 to 2001 were reviewed retrospectively. A telephone survey was attempted for all. Seventy-five (42%) responded to the Cleveland Clinic Incontinence Score (CCIS), KESS Constipation Score (KESS-CS), and SF-36 Quality of Life Score. Appropriate statistical analysis was performed. RESULTS: For the 122 AO and 55 PO, there were no deaths. Mean follow-up was similar (PO 3.1 vs. AO 3.9 years; P = 0.306). As expected the PO patients were older (mean 69 vs. 55 years) and had higher ASA scores. Those undergoing PO had less procedural blood loss, operative time, hospital stay, and dietary restriction. The PO group also scored worse on the physical component of SF-36 (PO 33 vs. AO 39.6; P = 0.034). However, the rate of recurrent prolapse was significantly higher for the PO (PO 26.5% vs. AO 5.2%; P < 0.001). Complications, CCIS, KESS-CS, and SF-36 mental component were similar in both groups. CONCLUSIONS: In full-thickness rectal prolapse, elderly, sick patients are selected for a perineal operation. The morbidity, functional outcomes, and quality of life are acceptable. However, the high recurrence rates make the perineal operation a second-best choice for younger, healthy patients.

Evaluation of association between precolectomy thrombocytosis and the occurrence of inflammatory pouch disorders.

BACKGROUND: There are inconsistencies regarding the risk factors associated with pouchitis and Crohn's disease of the pouch after ileal pouch-anal anastomosis. The aim of this study was to evaluate the associations between precolectomy routine laboratory tests, including platelet counts, and occurrences of inflammatory pouch disorders. METHODS: All eligible patients were included from The Pouchitis Clinic. All patients undergoing ileal pouch-anal anastomosis for ulcerative colitis were included if their preoperative laboratory tests were available. Demographic, clinical, endoscopic, and laboratory tests were evaluated with univariate and multivariate analyses. RESULTS: A total of 251 patients were included. Fifty-five patients had acute pouchitis and 29 had chronic pouchitis. Forty-two patients were diagnosed with Crohn's disease of the pouch. In multivariate analysis, elevated platelet count was not associated with chronic pouchitis (odds ratio, 0.91; 95% confidence interval, 0.32-2.59; P = 0.86) or Crohn's disease of the pouch (odds ratio, 0.87; 95% confidence interval, 0.38-1.97, P = 0.73) after adjusting for gender, smoking, extraintestinal manifestations, and pouch duration. Active smoking was associated with Crohn's disease of the pouch (odds ratio, 5.64; 95% confidence interval, 1.98-16.1; P = 0.001). No other laboratory tests, including white blood cell counts, albumin levels, and hemoglobin levels, were associated with the pouch outcomes. The presence of extraintestinal manifestations was associated with acute pouchitis (odds ratio, 1.89; 95% confidence interval, 0.95-1.14; P = 0.05) and chronic pouchitis (odds ratio, 2.6; 95% confidence interval, 1.13-5.87; P = 0.03). CONCLUSION: Precolectomy laboratory tests, including platelet counts, did not appear to impact the occurrence of inflammatory pouch disorders after ileal pouch-anal anastomosis.

Frequency and impact of pulmonary hypertension in patients with obstructive sleep apnea syndrome.

The correlates and consequences of pulmonary hypertension (PH) associated with obstructive sleep apnea (OSA) are poorly understood. Patients undergoing pulmonary artery catheterization within 6 months of an overnight polysomnography showing OSA were included in the present analysis. A total of 83 patients with complete data were analyzed (no PH, n = 25 [30%]; PH, 58 [70%]; of these, 18 had a pulmonary capillary wedge pressure of <15 mm Hg). No significant differences were observed between the PH and no PH groups regarding age or apnea-hypopnea index. The correlates of PH were elevated right ventricular systolic pressure (p <0.001), body mass index (p = 0.026), female gender (p = 0.01), nocturnal desaturation (82% vs 18%), and forced vital capacity <70% (p = 0.04) on univariate analysis and female gender (p = 0.03), age <49 years (p = 0.02), body mass index of > or =26 kg/m(2) (p = 0.08), and right ventricular systolic pressure of > or =30 mm Hg (p <0.001) on multivariate analysis. Patients with PH had a lower 6-minute walk distance (285.5 +/- 122 m vs 343 +/- 213 m, p = 0.4). The survival rate at 1, 4, and 8 years for patients with PH was 93%, 75%, and 43% compared to 100%, 90%, and 76% for patients without PH, respectively. Patients with severe PH (n = 27; 33%) had more nocturnal desaturation (p = 0.045), worse pulmonary hemodynamics, and greater mortality (37%) than the groups with mild or moderate PH (16%) or no PH (16%). In conclusion, our results have shown that, although generally mild to moderate, severe PH can occur in patients with OSA. Female gender, younger age, obesity, and nocturnal desaturation were associated with PH. PH can cause functional limitations and increased mortality in patients with OSA.

Divergent oncogenic changes influence survival differences between colon and rectal adenocarcinomas.

PURPOSE: Colorectal cancers develop through various mechanisms such as chromosomal instability, DNA mismatch repair deficiency (microsatellite instability), and epigenetic DNA promoter methylation (CpG island methylator phenotype). This study evaluated the disparity in neoplastic changes between colon and rectal cancers. METHODS: A clinic-based colorectal frozen tumor bank at a single institution was queried for colon and rectal adenocarcinomas. Tumor DNA was extracted and analyzed for microsatellite instability, methylation, and mutations in the oncogenes KRAS and BRAF. Patient demographics, tumor characteristics, and clinical outcomes were compared. RESULTS: The 268 patients with colon cancer and 89 with rectal cancer were similar in gender, tumor size, stage, and differentiation. Colon cancers had a higher incidence of microsatellite instability (27 percent) and methylator phenotype (28 percent) compared with rectal cancers (7 percent, 3 percent, respectively; P < 0.001). Although KRAS mutation rate was similar, colon cancers had a higher incidence of BRAF mutations (16.7 percent vs. 0 percent; P < 0.001). Microsatellite stable tumors had an increased risk of disease recurrence compared with microsatellite unstable tumors (odds ratio, 3.86). Despite overall differences in outcome between colon and rectal cancers, no significant difference in survival existed when similar molecular phenotypes were compared across anatomic sites. CONCLUSIONS: Although colon cancers are molecularly heterogeneous, rectal cancers arise mostly via a single neoplastic pathway. Genetic and molecular differences influence prognosis more than anatomic location and suggest that oncogenic pathways contribute to survival differences between colon and rectal cancers.

Sacral neuromodulation for the treatment of fecal incontinence and urinary incontinence in female patients: long-term follow-up.

PURPOSE: The purpose of this study was to evaluate improvement in symptoms of fecal incontinence (FI) in a group of women who also had urinary incontinence (UI) and were successfully implanted with the sacral neuromodulation (SNM) device primarily for urinary incontinence in one US institution. METHODS: Twenty-four patients with FI and UI who failed to improve with conservative or standard surgical treatment underwent permanent SNM after a successful peripheral nerve stimulation test during 2003-2007. Wexner incontinence score, fecal incontinence quality of life (FIQL), and Bristol stool scales were recorded before and after treatment. Follow-up was done by questionnaires contact. RESULTS: Twenty-four patients (mean age 56.5 +/- 5.3 years) were studied. The median follow-up was 28 months (range 3-49). Twenty-two patients (92%) were contacted. Seven patients (31.8%) experienced improvement in both urinary and fecal incontinence symptoms. Twelve patients (54.5%) experienced no improvement in FI symptoms after SNM. Four patients required a colostomy or ileostomy; four had the system explanted (two, due to a faded clinical response and two, due to infection); and four other patients experienced no improvement after SNM. The outcomes of ten patients (45.5%) with functioning SNM were reviewed. There were significant improvement of FI symptoms with a significantly lower Wexner score from 12.0 +/- 2.0 before SNM to 4.7 +/- 3.6 (p = 0.009). The mean FIQL scores improved significantly from the baseline score 7.8 +/- 0.8 before SNM to 13.5 +/- 2.6 (p = 0.009). Bristol stool form scale was reduced significantly from 4.5 to 3.5 after SNM (p = 0.02). CONCLUSIONS: SNM may be beneficial in selected female patients with UI associated with FI. Prospective trials may help delineate which patients will show FI improvement in this combined group.

Predicting success of endoscopic aspiration for suspected pancreatic cystic neoplasms.

CONTEXT: Analysis of pancreatic cyst fluid can play a role in the management of asymptomatic cystic neoplasms. OBJECTIVE: Our aim was to determine whether cyst size or location can predict the success of cyst fluid collection and analysis. DESIGN: Review of prospective management protocol. SETTING: Tertiary care referral center. PATIENTS: Three-hundreds and 70 patients with suspected pancreatic cystic neoplasms evaluated over 6 years. INTERVENTIONS: Endoscopic ultrasound aspiration for up to 3 variables: cytology including extracellular mucin, CEA, and amylase. MAIN OUTCOME MEASURES: The number of variables obtained were compared with cyst size and location. RESULTS: The distribution of unilocular cystic lesions was: 125 (33.8%) head, 105 (28.4%) tail, 77 (20.8%) body, 37 (10.0%) uncinate and 13 (3.5%) multiple cysts. In addition, 13 (3.5%) patients had uncertain cyst location. There was no association between cyst location and number of variables obtained (P=0.148). An aspirate was obtained in 284 patients (76.8%) with a mean volume of 8.3 mL. There was a significant correlation between cyst size and volume aspirated (P<0.001). The number of variables obtained was significantly correlated with cyst size (P<0.001): 3 variables were obtained in 109 out of 284 (38.4%) with a median size of 3.0 cm. Logistic regression curves predict likelihood of success based on cyst size. An unsuccessful attempt at EUS aspiration for cysts occurred in 31 of the 284 cases (10.9%) with a median size of 1.5 cm. CONCLUSIONS: Successful endoscopic ultrasound aspiration of pancreatic cysts is independent of cyst location, but correlates with size, which can be useful in deciding which patients should undergo endoscopic ultrasound and aspiration.

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.

A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.

INTRODUCTION: Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer. AIM: : To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer. METHODS: A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed. RESULTS: Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 +/-12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups. CONCLUSIONS: In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

The outcome after restorative proctocolectomy with or without defunctioning ileostomy.

PURPOSE: Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy. METHODS: Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared. RESULTS: Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes. CONCLUSIONS: For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

Anal manometric parameters: predictors of outcome following anal sphincter repair?

Controversy exists over the utility of manometry in the management of fecal incontinence. In light of newer methods for the management of fecal incontinence demonstrating favorable results, this study was designed to evaluate manometric parameters relative to functional outcome following overlapping sphincteroplasty. Twenty women, 29 to 84 years of age (mean age 50 years), with severe fecal incontinence and large (>or=50%) sphincter defects on ultrasound were studied. All participants underwent anal manometry (mean resting pressure, mean squeeze pressure, anal canal length, compliance), pudendal nerve terminal motor latency (PNTML) testing, and completed the American Society of Colon and Rectal Surgeons fecal incontinence severity index (FISI) survey before and 6 weeks after sphincter repair. Statistical analysis for all data included the Wilcoxon rank-sum test, Mann-Whitney test, and Spearman's correlation. Significant perioperative improvement was seen in the absolute resting and squeeze pressures and anal canal length. Overlapping sphincteroplasty was also associated with significant improvement in fecal incontinence scores (FISI 36 vs. 16.4; P=0.0001). Although no single preoperative manometric parameter was able to predict outcome following sphincteroplasty, preoperative mean resting and squeeze pressures as well as anal canal length inversely correlated with the relative changes in these parameters achieved postoperatively. These findings suggest that either the physiologic parameters studied are not predictive of functional outcome or the scoring system used is ineffective in determining function. The perioperative paradoxical changes in resting pressure, squeeze pressure, and anal canal length would support the use of overlapping sphincteroplasty in patients with significant sphincter defects and poor anal tone.