Intracorporeal Vessel Ligation in Laparoscopic Right Colectomy for Cancer is Associated with Increased Lymph Node Yield.

BACKGROUND: This study aimed to compare intra- and extracorporeal division of the vascular pedicle in laparoscopic right colectomy regarding pathological outcomes, short-term morbidity, and local recurrence and distant metastases. METHODS: Retrospective analysis of an IRB-approved database of all patients who underwent laparoscopic right colectomy for cancer between 01/2011 and 08/2021. Main outcome measures were number of harvested lymph nodes, length of resected colon, R1 rate, positive lymph node ratio, short-term post-operative morbidity, local recurrence, and distant metastases. RESULTS: Two-hundred seventy-one consecutive patients (136 males) patients underwent laparoscopic right hemicolectomy for cancer during the study period. Vessel ligation was intracorporeal in 171 (63%) and extracorporeal in 100 patients (37%); groups had similar baseline characteristics except for extent of resection as extended right hemicolectomy was significantly more often performed in the intracorporeal group. When the two groups were matched for the extent of resection (standard versus extended right hemicolectomy), the mean number of harvested lymph nodes (28.61 ± 12.04 versus 25.37 ± 10.06, p = 0.04) and median length of the resected colon [26.00 (IQR: 21.00, 32.00) versus 23.00 (IQR: 19.00, 27.00) cm, p = 0.003] were significantly higher in the intracorporeal than in the extracorporeal group. The intracorporeal group required a significantly longer operative time than did the extracorporeal group (168.94 ± 57.9 vs. 139.7 ± 41.3 mins, p = 0.001). No significant differences were noted between the groups in terms of ileus, hemorrhage, surgical site infection, re-operation rates, recurrence, or distant metastases. CONCLUSION: Intracorporeal vessel ligation in laparoscopic right hemicolectomy was associated with increased lymph node yield and longer specimens, although requiring longer operative times. Postoperative clinical outcomes were similar to outcomes in the extracorporeal ligation group.

Does Completeness of the Mesorectal Excision Still Correlate With Local Recurrence?

BACKGROUND: Total mesorectal excision is the standard surgical procedure for rectal cancer treatment. Several studies have shown a close correlation between the prognosis of patients with rectal cancer and the completeness of the mesorectal specimen. OBJECTIVE: To assess the correlation between macroscopic assessment of mesorectal excision and long-term oncological outcomes. DESIGN: Retrospective analysis of an Institutional Review Board-approved database. SETTINGS: Tertiary referral center. PATIENTS: Patients with rectal cancer who were operated on between March 2016 and October 2019 were classified into 3 groups based on the mesorectal specimen quality: complete, near complete, and incomplete. Only patients with a follow-up of ≥2 years and without signs of preoperative distant disease were included. MAIN OUTCOME MEASURES: Relationship between total mesorectal excision and local and distant recurrence rates in patients with rectal cancer. RESULTS: A total of 124 patients (35.5% females) were included in the analysis, with a mean age of 58.1 (SD 12) years and a mean BMI of 26.4 (SD 4.59) kg/m². Neoadjuvant chemoradiation was administered to 71% of patients, whereas 13.7% received total neoadjuvant therapy. Restorative procedures were performed in 107 patients (86.3%), whereas 17 patients (13.7%) underwent abdominoperineal resection. The majority of mesorectal excision specimens (87.09%) were complete or near complete. Local recurrence rates were 6.3% (1/16) in the incomplete and 7.4% (8/108) in the complete/near complete group ( p = 0.86). Metachronous distant metastases occurred in 6 patients (37.5%) in the incomplete group and in 24 patients (22.2%) in the complete/near complete group (p = 0.18). Thus, specimen quality did not appear to impact disease-free survival. LIMITATIONS: Retrospective, single-center study with relatively short follow-up. CONCLUSIONS: In the era of a multidisciplinary approach and extensive use of neoadjuvant therapy, macroscopic completeness of total mesorectal excision may not be as valuable a prognosticator as in the past. Larger studies with longer follow-ups are needed to clarify these preliminary findings. See Video Abstract at http://links.lww.com/DCR/C129. LA INTEGRIDAD DE LA ESCISIN MESORRECTAL TODAVA SE CORRELACIONA CON LA RECURRENCIA LOCAL: ANTECEDENTES:La escisión total desl mesorrecto es el estándar de oro para el tratamiento del cáncer de recto. Varios estudios han demostrado una estrecha correlación entre el pronóstico de los pacientes con cáncer de recto y la integridad espécimen mesorrectal.OBJETIVO:Evaluar la correlación entre la evaluación macroscópica de la escisión mesorrectal y los resultados oncológicos a largo plazo en pacientes con cáncer de recto.DISEÑO:Análisis retrospectivo de una base de datos aprobada por el IRB.ENTORNO CLINICO:El estudio se realizó en un centro de referencia terciario de una sola institución.PACIENTES:Todos los pacientes con cáncer de recto operados entre 3/2016-10/2019. Los pacientes se clasificaron en 3 grupos, según la calidad del espécimen mesorrectal: completo, casi completo e incompleto. Solo se incluyeron pacientes con seguimiento >2 años y sin signos de enfermedad a distancia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Identificar la relación entre la escisión mesorrectal total y las tasas de recurrencia local y a distancia en pacientes con cáncer de recto.RESULTADOS:Se incluyeron 124 pacientes (35,5% mujeres) con una edad media de 58,1 años (DE 12) y un índice de masa corporal medio de 26,4 (DE 4,59). Se administró quimiorradiación neoadyuvante al 71% de los pacientes, mientras que el 13,7% recibió terapia neoadyuvante total. Se realizaron procedimientos de restauración en 107 pacientes (86,3%), mientras que 17 pacientes (13,7%) se sometieron a resección abdominoperineal. La mayoría (87,09%) de los especímenes de escisión mesorrectal fueron completas o casi completas. Las tasas de recurrencia local fueron 1/16 (6,3%) en el grupo incompleto y 8/108 (7,4%) en el grupo completo/casi completo ( p = 0,86). Se produjeron metástasis a distancia metacrónicas en 6 pacientes (37,5%) en el grupo incompleto y 24 (22,2%) en el grupo completo/casi completo ( p = 0,18). Por lo tanto, la calidad del espécimen no pareció afectar la supervivencia libre de enfermedad.LIMITACIONES:Estudio retrospectivo de un solo centro con pequeño número de casos y seguimiento relativamente corto.CONCLUSIÓN:En la era de un enfoque multidisciplinario y el uso extensivo de la terapia neoadyuvante, la integridad macroscópica de la escisión total del mesorrecto, puede no ser un pronóstico tan valioso como en el pasado. Se necesitan estudios más amplios con períodos de seguimiento más prolongados para aclarar estos hallazgos preliminares. Consulte Video Resumen en http://links.lww.com/DCR/C129 . (Traducción-Dr. Fidel Ruiz Healy ).

Does nasogastric tube decompression get used less often with laparoscopic and hand-assisted compared with open colectomy?

INTRODUCTION: Laparoscopic surgery is associated with well-known benefits, one of which is earlier return of bowel function. Since the laparoscopic approach to colon resections was introduced in the early 1990s, it has become the standard of care. Hand-assisted laparoscopic surgery (HALS) is a surgical approach in which dissection is facilitated by the surgeon's hand within the abdominal cavity during laparoscopy. The purpose of this study was to compare the incidence of postoperative ileus and the need for nasogastric tube (NGT) decompression in patients undergoing elective colon resections. METHODS AND PROCEDURES: Following institutional review board approval, we performed a retrospective review of a prospectively collected database. Included were patients who underwent elective left-sided large bowel resections between 2009 and 2012. Exclusion criteria were urgent operation, stoma creation, ASA IV classification, NGT left in place at the end of surgery, and postoperative anastomotic leakage. Patients were divided into three groups: laparoscopic surgery, HALS, and open surgery. We evaluated the incidence of postoperative ileus and the use of nasogastric decompression in each group. RESULTS: A total of 243 patients were included in this study; 73 patients underwent open surgery, 89 patients underwent HALS, and 81 patients underwent laparoscopic surgery. The proportion of patients who needed postoperative nasogastric decompression was significantly reduced in patients undergoing laparoscopic surgery (3.7%) or HALS (4.5%) compared with those who underwent open resection (17.8%). The time from surgery to first flatus and first bowel movement, the time to tolerate solid diet, and the total length of postoperative hospital stay also were all significantly reduced in the laparoscopic and HALS groups compared with the open surgery group. There were no significant differences in any of these measures between the laparoscopic group and the hand-assisted group. CONCLUSIONS: Like laparoscopy, HALS is associated with less postoperative ileus and necessitates less NGT decompression than does open surgery.

A novel approach to assessing technical competence of colorectal surgery residents: the development and evaluation of the Colorectal Objective Structured Assessment of Technical Skill (COSATS).

OBJECTIVE: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS). BACKGROUND: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards. METHODS: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice." RESULTS: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent. CONCLUSIONS: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

Surgical outcomes and their relation to the number of prior episodes of diverticulitis.

PURPOSE: We aimed to investigate the relationship between the number of prior episodes of diverticulitis and outcomes of sigmoid colectomy. METHODS: After institutional review board approval, a retrospective review was undertaken based on records of patients who underwent sigmoid resection with anastomosis for diverticulitis between 4 May 2007 and 29 February 2012. Patients were divided into two groups: 0-3 attacks (group 1) and ≥4 attacks (group 2). Statistical analyses were performed to determine whether the groups differed on demographic, intra-operative and postoperative variables. RESULTS: We identified 247 patients who underwent sigmoid colectomy for diverticulitis (45 open, 202 laparoscopic). The two groups did not differ significantly in age, gender, American Society of Anesthesiologists score, past surgical history, body mass index, length of stay, use of a stoma or number of prior hospitalizations for diverticulitis. Group 1 had a higher rate of abscesses (30.6 vs 6.8%, P < 0.001) and fistulas (19.4 vs 0.9%, P < 0.001); a longer operative time (190.1 vs 166.3 min, P = 0.0024); and higher rates of postoperative complications (45.8 vs 23.3%, P < 0.001) and conversion (17.1 vs 4.4%, P = 0.0091). The most common surgical complications in groups 1 and 2 were wound infection (35 vs 10) and ileus (20 vs 8). Based on multivariate regression analysis, ≥4 attacks were independently correlated with a lower complication rate (odds ratio = 0.512, 95% confidence interval = 0.266-0.987, P = 0.046). CONCLUSIONS: Patients who had ≥4 previous attacks of diverticulitis had fewer postoperative complications.

Loop ileostomy closure after laparoscopic versus open surgery: is there a difference?

BACKGROUND: Temporary loop ileostomy is commonly performed to protect the distal anastomosis during both open and laparoscopic colectomies. This study aimed to evaluate the impact of initial open and laparoscopic colorectal resection on the outcomes of ileostomy closure. METHODS: After institutional review board approval, all patients who underwent loop ileostomy closure from January 2008 to July 2012 were identified. The patients' demographics, diagnosis, American Society of Anesthesiology (ASA) classification, type of resection, approach (laparoscopic [LS] or open [OS] surgery), use of anti-adhesion barrier, and ileostomy closure outcomes were obtained from a chart review. The outcomes of ileostomy closure after LS and OS colorectal resections were compared using Chi-square for categorical variables and Student's t test for continuous variables. RESULTS: The study identified 351 patients with a mean age of 51 years: 145 patients (41.2%) in the LS group and 206 patients (58.8%) in the OS group. The most common procedures performed were total proctocolectomy with ileal J pouch anal anastomosis (109 patients: 49 LS, 60 OS) and restorative proctectomy (99 patients: 34 LS, 65 OS). At the time of ileostomy closure, the patients in the LS group had a significantly shorter mean operative time (LS 60.9 vs OS 82.6 min; p < 0.001) and a shorter hospital stay (LS 4.9 vs OS 5.8 days; p = 0.042). The overall complication rate was 20.1% (70 patients), and the rate in the OS group was significantly higher (p = 0.028). The most common complications were postoperative ileus (41 patients: 13 LS vs 28 OS) and enterocutaneous fistula (5 patients, all in the OS group). CONCLUSIONS: Loop ileostomy closure after laparoscopic colorectal surgery is associated with a significantly shorter operative time and hospital stay as well as a lower rate of postoperative complications. Superior outcomes after loop ileostomy closure lend further support to the use of laparoscopy.

Hartmann reversal: obesity adversely impacts outcome.

BACKGROUND: Comprehensive analyses are lacking to identify predictors of postoperative complications in patients who undergo a Hartmann reversal. OBJECTIVE: The aim of this study is to identify predictive factors for morbidity after reversal. DESIGN: This study is a retrospective review of prospectively collected data. SETTINGS: The study was conducted at Cleveland Clinic Florida. PATIENTS: Consecutive patients from January 2004 to July 2011 who underwent reversal were included. MAIN OUTCOME MEASURES: Variables pertaining to Hartmann procedure and reversal were obtained for analyses in patients with and without postoperative complications. Univariate and multivariate analyses were performed. RESULTS: A total of 95 patients (mean age 61 years, 56% male) underwent reversal, with an overall morbidity of 46%. Patients with and without complications had similar demographics, comorbidities, diagnoses, and Hartmann procedure intraoperative findings. Patients with complications after reversal were more likely to have prophylactic ureteral stents (61% vs 41%, p < 0.05) and an open approach (91% vs 75%, p < 0.04). Complications were associated with longer hospital stay (8.8 vs 6.9 days,p < 0.006) and higher rates of reintervention (9% vs 0%, p < 0.03) and readmission (16% vs 2%, p < 0.02). Predictors of morbidity after reversal included BMI (29 vs 26 kg/m, p < 0.04), hospital stay for Hartmann procedure (15 vs 10 days, p < 0.03), and short distal stump (50% vs 31%, p < 0.05). BMI was the only independent predictor of morbidity (p < 0.04). Obesity was associated with significantly greater overall morbidity (64% vs 40%, p < 0.04), wound infections (56% vs 31%, p < 0.04), diverting ileostomy at reversal (24% vs 13%, p < 0.05), and time between procedures (399 vs 269 days, p < 0.02). LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Hartmann reversal is associated with significant morbidity; BMI independently predicts complications. Therefore, patients who are obese should be encouraged or even potentially required to lose weight before reversal.

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

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

Fecal incontinence: etiology, evaluation, and treatment.

Fecal incontinence is a debilitating problem facing ~2.2% of the U.S. general population over 65 years of age. Etiologic factors include traumatic, neurologic, congenital, and iatrogenic. Most commonly, obstetric trauma causes fecal incontinence as well as poorly performed anorectal surgery or pelvic radiation. Several severity scores and quality of life indexes have been developed to quantify incontinent symptoms. There are several nonsurgical and surgical options for the treatment of fecal incontinence. Biofeedback is among the most successful nonoperative strategies. Depending on the cause, anal sphincter repair, artificial bowel sphincter, and sacral nerve stimulation are used to treat fecal incontinence with some success. Unfortunately, fecal incontinence is an extremely difficult problem to manage: there has not been one, single treatment option that has proven to be both safe and effective in long-term studies.

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

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

What are the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery?

PURPOSE: Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery. METHODS: The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence. RESULTS: Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohn's disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohn's disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohn's disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent. CONCLUSION: Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeon's preference and patient-related factors such as diagnosis.

Anal fistula plug: initial experience and outcomes.

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

What is the definition of "conversion" in laparoscopic colorectal surgery?

BACKGROUND: A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery. METHODS: Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s). RESULTS: 325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5-12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case. CONCLUSIONS: It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.

Conversion in laparoscopic surgery: does intraoperative complication influence outcome?

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

Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure?

BACKGROUND: Anastomotic complications such as leakage and bleeding remain among the most serious complications of laparoscopic colorectal surgery. No perfect method exists for accurate and reliable avoidance of these catastrophes. This study aimed to study the usefulness of routine intraoperative endoscopy (RIOE) by comparing the surgical outcomes for RIOE patients with those for selective intraoperative endoscopy (SIOE) patients. METHODS: A retrospective chart review was performed for consecutive patients who underwent elective laparoscopic colorectal resections with distal anastomosis between January 2004 and May 2007. One surgeon performed RIOE, whereas the other three surgeons performed SIOE as necessary. All the abnormalities of IOE patients were managed with a subsequent salvage procedure, and the postoperative outcomes were compared between the RIOE and SIOE groups. RESULTS: The study included 107 patients in the RIOE group and 137 patients in the SIOE group. Abnormalities were detected in 11 RIOE patients (10.3%) (six with staple line bleeding, three with positive air leak test results, and two with additional pathology identified). All but one abnormality was laparoscopically managed without conversion to laparotomy. Whereas one patient experienced postoperative staple line bleeding that required a second operation, the remaining 10 patients recovered uneventfully. The mean hospital stay was 6 days (range, 4-9) days. The RIOE group had overall rates of 0% for anastomotic leakage and 0.9% for staple line bleeding. Intraoperative endoscopies were performed for 30 (21.9%) of the 137 patients in the SIOE group. The postoperative outcomes comparison between the RIOE and SIOE groups showed a tendency toward more overall anastomotic complications (0.9% vs. 5.1%) in the SIOE group, which due to the small sample size did not translate into significant differences in terms of staple line bleeding and anastomotic leakage. There also were no significant differences in other outcomes such as ileus, abdominal or pelvic sepsis, reoperation, positive distal margin, distance from distal margins, length of hospital stay, or mortality. CONCLUSIONS: Routine IOE for patients undergoing elective laparoscopic colorectal surgery with distal anastomosis can detect abnormalities at or around the anastomosis. Although the RIOE group had fewer postoperative anastomotic complications, due to the small sample size, the 5.7-fold increase in anastomotic failure did not translate into significantly better postoperative outcomes than the SIOE group experienced. A larger-scale single or multicenter prospective randomized study or a metaanalysis including similar studies is necessary for further investigation of this issue.

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.

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

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

Functional disorders: rectoanal intussusception.

Rectoanal intussusception (RI) is a telescoping of the rectal wall during defecation. RI is an easily recognizable physiologic phenomenon on defecography. The management, however, is much more controversial. Two predominant hypotheses exist regarding the etiology of RI: RI as a primary disorder, and RI as a secondary phenomenon. The diagnosis may be suspected based on clinical symptoms of obstructive defecation. Diagnostic modalities include defecography as the gold standard. Dynamic pelvic magnetic resonance imaging (DPMRI) and transperineal ultrasound are attractive alternatives to defecography; however, their sensitivity is poor in comparison to the gold standard at this time. Management strategies including conservative measures such as biofeedback and surgical procedures including mucosal proctectomy (Delorme), rectopexy, and stapled transanal rectal resection (STARR) procedures have varied degrees of efficacy.

Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes.

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is a rare disorder often misdiagnosed as a malignant ulcer. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless, the endoscopic and clinical presentations may be confusing. The aim of the present study was to assess the clinical findings, surgical treatment, and outcomes in patients who suffer from SRUS. MATERIALS AND METHODS: A retrospective chart review was undertaken, from January 1989 to May 2005 for all patients who were diagnosed with SRUS. Data recorded included: patient's age, gender, clinical presentation, past surgical history, diagnostic and preoperative workup, operative procedure, complications, and outcomes. RESULTS: During the study period, 23 patients were diagnosed with SRUS. Seven patients received only medical treatment, and in three patients, the ulcer healed after medical treatment. Sixteen patients underwent surgical treatment. In four patients, the symptoms persisted after surgery. Two patients presented with postoperative rectal bleeding requiring surgical intervention. Three patients developed late postoperative sexual dysfunction. One patient continued suffering from rectal pain after a colostomy was constructed. Median follow-up was 14 (range 2-84) months. CONCLUSION: The results of this study show clearly that every patient with SRUS must be assessed individually. Initial treatment should include conservative measures. In patients with refractory symptoms, surgical treatment should be considered. Results of anterior resection and protocolectomy are satisfactory for solitary rectal ulcer.

Strictureplasty.

Strictureplasty in patients with Crohn's disease is an option in the colorectal surgeon's armamentarium for fibrostenotic obstructive disease. Common types include the Heineke-Mikulicz strictureplasty, Finney strictureplasty, and the side-to-side isoperistaltic strictureplasty. The procedure has potential for significant morbidity; therefore, it should be chosen for the patient carefully. Strictureplasty complements bowel resection in Crohn's disease; it is an excellent procedure to reduce the risk of developing short-bowel syndrome and its associated complications.