Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial.

BACKGROUND: Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections. MATERIALS AND METHODS: Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea. RESULTS: One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups. CONCLUSION: Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.

Randomized clinical trial of Lichtenstein's operation versus mesh plug for inguinal hernia repair.

BACKGROUND: Two of the most commonly used open prosthetic tension-free techniques for inguinal hernia repair are Lichtenstein's operation and the mesh plug repair. The technique of choice remains a subject of ongoing debate. The objective of the present investigation was to compare the two surgical procedures with respect to associated morbidity and recurrence rates. METHODS: Five hundred and ninety-five patients with 700 primary or recurrent inguinal hernias were randomized to undergo either Lichtenstein's operation or mesh plug repair. The primary endpoint of the investigation was the recurrence rate 1 year after surgery. Secondary endpoints were perioperative complications and reoperation rates. RESULTS: At 12-month follow-up, 597 hernia repairs (85.3 per cent) were evaluated. There were no significant differences regarding recurrence rates and perioperative complications. However, there was a significant difference in the overall reoperation rate between the two treatment groups, with 13 reoperations (4.2 per cent) in the Lichtenstein group and four (1.4 per cent) in the mesh plug group (P = 0.047). CONCLUSION: Lichtenstein's operation and the mesh plug repair are comparable with respect to perioperative complications and recurrence rates.

Ileocecal reservoir reconstruction after total mesorectal excision: functional results of the long-term follow-up.

BACKGROUND: The aim of this study is to obtain functional results of the long-term follow-up after TME and ileocecal interposition as rectal replacement. METHODS: The study included patients operated on between March 1993 and August 1997 who received an ileocecal interposition as rectal replacement. Follow-up was carried out 3 and 5 years postoperatively. For statistical analysis, the paired t-test, rank test (Wilcoxon), and chi-square or Fisher's exact test were applied; level of significance, P<0.05. RESULTS: Forty-four patients were included in the studies. Of these, five were not available and four patients could not be evaluated (dementia 1, radiation proctitis 1, fistula 1, pouchitis 1). Seventeen patients died during the observation period; 12 died of the disease. Recurrence of the disorder occurred in 2 of 35 patients (5.7%); 26 and 18 patients, 3 and 5 years postoperatively, respectively remained in the study. At 5 years, 78% of the patients were continent; mean stool frequency was 2.5+/-1.6 per day. CONCLUSIONS: Functional results and subjective assessment of ileocecal interposition were constant at 3 and 5 years postoperatively. If construction of a colonic J-pouch is not possible due to lack of colonic length, especially after prior colonic resections, the ileocecal interpositional reservoir may offer an alternative to rectal replacement.

Laparoscopic surgery for inflammatory bowel disease.

BACKGROUND: Common laparoscopic colorectal procedures in patients with Crohn's disease include ileocolic resection and subtotal colectomy. The aim of this study was to compare and contrast the results of these two procedures. METHODS: Patients who underwent one of these procedures between June 1992 and January 1999 were identified and included in the study. Statistical analysis was performed using the Mann-Whitney test, Student's t-test, or Fisher's exact test. RESULTS: In all 109 patients (63 women and 46 men) with an average age of 36.7 years (range, 15-74) underwent ileocolic resection (ICR), while 21 patients (16 women and five men) with an average age of 36.5 years (range, 18-77) underwent subtotal colectomy (STC) (p = NS). There were 14 intraoperative complications, eight (7%) in the ICR group and six (29%) in the STC group (p = 0.01). Total operative time was 167 min (range, 90-285) in the ICR group and 231 min (range, 140-340) in the STC group (p < 0.01). Despite this difference in operating time, the hospital stays were very similar at 8.8 days (range, 3-27) and 8.8 days (range, 3-14) (p = NS). In 19 (17%) of the ICR patients and five (24%) of the STC patients, their procedure was converted to a laparotomy (p = NS). In the ICR group, 20 of the patients (18%) had surgery-related postoperative complications, including five anastomotic leaks. In the STC group, six of the patients (29%) had surgery-related complications, including two anastomotic leaks (p = NS). CONCLUSION: Although STC is a far more extensive procedure than ICR, the overall postoperative complication rate is not significantly different between the two groups; however, we found that there were more intraoperative complications associated with STC.

Effect of age on the functional outcome of total abdominal colectomy for colonic inertia.

OBJECTIVE: Colonic inertia (CI) usually presents in women in the third decade of life; however, elderly patients are at times diagnosed with the disease. Total abdominal colectomy (TAC) is considered the preferred surgical treatment for patients with well established CI refractory to conservative and medical management. Surgeons are reluctant to proceed with colectomy in aged patients because of anticipated high morbidity and poor functional outcome. MATERIALS AND METHODS: We retrospectively reviewed the outcome in 14 patients over the age of 65 years (range 65-80) (Group I) who underwent TAC for CI between 1988 and 1996. The functional and clinical outcome was compared with that of 41 patients under the age of 65 (range 21-61) (Group II) operated upon during the same time period. Functional outcome was assessed by postal and telephone questionnaires at least 12 months following surgery. RESULTS: There was no major postoperative morbidity in either group. Three (21%) patients in Group I developed small bowel obstruction postoperatively and, of them, 2 required surgical treatment. In Group II the rate of obstruction was 7% (3 patients), with one patient requiring surgery. One patient in Group I subsequently underwent completion proctectomy and creation of an end ileostomy due to continued panenteric hypomotility. Three patients in Group I died during follow-up from causes unrelated to surgery. The mean frequency of spontaneous bowel movements following surgery was 3.8 (range 1-10)/day in Group I and 2.9 (range 1-8)/day in Group II (P=NS). 'Excellent' outcome was reported by 7 patients (64%) in Group I and 39 patients (95%) in Group II (P=0.01). CONCLUSION: TAC can be performed in elderly patients with established CI with acceptable functional results and no increase in morbidity, resulting in lifestyle improvement. Complete physiological evaluation with increased emphasis on small bowel and gastric motility studies is required in this patient population.

Do prior abdominal operations alter the outcome of laparoscopically assisted right hemicolectomy?

BACKGROUND: Adhesions can increase the difficulty of both laparoscopic surgery and laparotomy. The aim of this study was to compare the results of laparoscopically assisted right hemicolectomy in patients after prior abdominal operations (PAOs) with the results in patients without prior abdominal operations (NPAOs). METHODS: Between August 1991 and September 1998, 85 patients underwent laparoscopically assisted right hemicolectomy. The Mann-Whitney test or Fisher's exact test was used for statistical analysis. RESULTS: In this study, 36 patients (21 women and 15 men), with an average age of 57.5 years (range, 15-87 years) had undergone a mean of 1.25 (range, 1 to 3) PAOs, whereas 49 patients (20 women and 29 men), with an average age of 60.0 years (range, 16 to 87 years) (p = 0.44) had undergone NPAOs. Overall in the PAO and NPAO groups, respectively, there were no significant differences in the incidence of intraoperative complications (3 versus 4; p = 1.0). The mean operative time was 151 min (range, 90 to 260 min) versus 148 min (range, 70 to 270 min) (p = 0.66), and the mean length of stay was 6. 8 days (range, 3 to 18 days) versus 7.6 days (range, 3 to 19 days) (p = 0.13). The procedure was converted to laparotomy (p = 0.754) for six patients in the PAO group (5 because of adhesions) and 6 patients in the NPAO-group (1 because of adhesions; p = 0.078). In the PAO group 17 patients (47%) had 22 postoperative complications: 11 general medical and 4 wound-related complications. Seven patients (19%) had prolonged postoperative ileus. In the NPAO-group 18 patients (38%) had a total of 22 complications: 7 general medical problems, 6 wound-related complications, and 8 prolonged postoperative ileus, none of which were statistically significant. One patient in the NPAO group had an anastomotic leak. During a mean follow-up period of 41 months (range, 3 to 89 months), three patients in the PAO group and four in the NPAO group developed incisional hernias. CONCLUSIONS: Although there is a trend toward more conversions because of adhesions in patients with a history of prior abdominal operations (p = 0.078), no increase in morbidity resulted. Therefore, laparoscopically assisted right hemicolectomy can be offered to patients with PAO, whose rate of adhesions can be expected to equal that of patients with NPAO.