Abdominal approaches for rectal prolapse.

The management of full-thickness rectal prolapse involves surgical intervention in the majority of cases. Many procedures have been described employing both perineal and abdominal approaches. Abdominal procedures result in more durable repair of the prolapse; however, the procedures require general anesthesia and are reserved for younger healthier patients. Laparoscopy has been utilized in the treatment of rectal prolapse since its introduction for colorectal procedures; recent studies have found equivalent long-term results and short-term outcomes.

Colorectal cancer screening: do we practice what we preach?

OBJECTIVE: Compliance rates for colorectal cancer screening have been reported as low, and ignorance is the most common factor sighted to explain this. The aim of this study was to determine screening compliance among colorectal surgeons assumed to be educated of the risks of colorectal cancer. METHODS: A postal survey was distributed to the members of the American Society of Colon and Rectal Surgeons. RESULTS: A total of 1195 members were surveyed. All respondents indicated that they advocate screening. Colonoscopy every 10 years and annual fecal occult blood testing were the most common strategies advocated to individuals with baseline risk. Colonoscopy every 5 years and annual fecal occult blood testing were the most common strategies advocated to patients with a first-degree relative with polyps or cancer. Most of these colorectal surgeons initiated their screening before 50 years of age. CONCLUSION: Colorectal cancer screening compliance is high among members of the American Society of Colon and Rectal Surgeons. These rates may be the result of awareness of the risks of colorectal cancer.

Is the quality of life better in patients with colostomy than patients with fecal incontience?

BACKGROUND: A colostomy offers definitive treatment for individuals with fecal incontinence (FI). Patients and physicians remain apprehensive regarding this option because the quality of life (QOL) with a colostomy is presumably worse than living with FI. The aim of this study, therefore, was to compare the QOL of colostomy patients to patients with FI. METHODS: A cross-sectional postal survey of patients with FI or an end colostomy was undertaken. QOL measures used included the Short Form 36 General Quality of Life Assessment (SF-36) and the Fecal Incontinence Quality of Life score (FIQOL). RESULTS: The colostomy group included 39 patients and the FI group included 71 patients. The average FI score for FI group was 12 +/- 4.9 (0 = complete continence, 20 = severe incontinence). In the colostomy group the average colostomy function score was 12.9 +/- 3.8 (7 = good function, 35 = poor function). Analysis of the SF-36 revealed higher social function score in the colostomy group compared to the FI group. Analysis of the FIQOL revealed higher scores in the coping, embarrassment, lifestyle scales, and depression scales in the colostomy group compared to the FI group. CONCLUSION: A colostomy is a viable option for patients who suffer from FI and offers a definitive cure with improved QOL.

Surgical management of pouch-vaginal fistula after restorative proctocolectomy.

BACKGROUND: Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. METHODS: After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. RESULTS: The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. CONCLUSIONS: Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Horseshoe abscesses and fistulas: how are we doing?

BACKGROUND: Various surgical treatments exist for horseshoe abscesses and fistulae, including posterior midline sphincterotomy, catheter drainage, cutting and draining setons, and advancement flaps. The aim of this study was to evaluate the long-term results of patients treated for these complex anorectal problems. METHODS: A retrospective review was undertaken of patients with a diagnosis of horseshoe abscess, horseshoe fistula, postanal space abscess, or postanal space fistula from 1990 to 2001. Long-term follow-up was accomplished by telephone questionnaire. RESULTS: Thirty-one patients were identified, of whom 17 (54.8%) had a diagnosis of Crohn disease. The diagnosis at presentation included unilateral (ischiorectal) abscess (32.3%), bilateral horseshoe abscess (51.6%), bilateral horseshoe fistula (9.7%), and postanal space abscess (6.4%). Endoanal ultrasonography was used during the preoperative evaluation in 11 patients (35.5%). After referral to our institution, patients underwent a median of four operations (range, 1 to 9). At a mean follow-up of 49.3 months, 60.7% of patients had either healed perineal disease or were asymptomatic with controlled disease. Patients who had a posterior midline sphincterotomy were more likely to be asymptomatic (P=.047). Patients who had a diagnosis of Crohn disease required more operations than those without Crohn disease (3 vs 1.86, P=.02). Only patients who had a diagnosis of Crohn disease had a stoma at their last follow-up (4 of 17, 23.5% vs 0 of 11, 0%; P=.05). CONCLUSIONS: Patients with horseshoe abscess or fistulae often require multiple operations for treatment but can expect reasonable rates of long-term success in controlling or curing their disease. Those who undergo posterior midline sphincterotomy seem to benefit with higher rates of improved symptoms. Patients with a diagnosis of Crohn disease may fare less well. The role of endoanal ultrasonography in directing therapy remains to be defined.

Correlating the Fecal Incontinence Quality-of-Life Score and the SF-36 to a proposed Ostomy Function Index in patients with a stoma.

Quality of life is affected by the creation of a stoma. To assess the validity of the Ostomy Function Index in patients with a stoma, a prospective survey was conducted from July 2000 to September 2001 among patients participating in local United Ostomy Association chapters (N = 99; 55 with a colostomy and 44 with an ileostomy). The Short Form 36 general health survey, Fecal Incontinence Quality of Life Scale, and the proposed Cleveland Clinic Florida Ostomy Function Index were used to assess general health and stoma function in patients with an ostomy. The average proposed function index score (7 = excellent function, 35 = poor function) was 11.97 (range 7 to 22). The proposed function Index correlated with the Fecal Incontinence Quality of Life Scale and the physical and mental component scales of the SF-36 (P < 0.05). The correlation between the proposed function index and the Fecal Incontinence Quality of Life Scale was stronger in colostomy than in ileostomy patients. With the exception of the SF-36 role-emotional domain in ileostomy patients, the function index correlated with all SF-36 scales (P <0.05) in both patient groups. The results of this study suggest that ostomy function is variable and correlates with quality of life and that the Fecal Incontinence Quality of Life Scale offers a limited assessment of quality of life in colostomy patients. The Cleveland Clinic Florida Ostomy Function Index offers an objective assessment of ostomy function that reflects on quality of life. Additional studies to refine measurement of quality of life in stoma patients are warranted.

Small bowel transit does not correlate with outcome of surgery in patients with colonic inertia.

Colonic inertia is a motility disorder that may involve dysfunction of the entire intestinal tract. The aim of this study was to assess whether small bowel transit time is associated with the outcome of total abdominal colectomy in patients with colonic inertia. A retrospective review of the medical records of patients who underwent total abdominal colectomy for colonic inertia was performed to identify those individuals who had a preoperative small bowel transit study. The outcome of surgery was correlated with the results of the small bowel transit study. Fifty-two female patients underwent total abdominal colectomy for colonic inertia between 1988 and 2000, of whom 17 (33%) had a preoperative small bowel transit study. The small bowel transit time was normal in 11 patients (65%), and the time was abnormally prolonged in 6 (35%). At a mean follow-up of 37 months, there was no significant difference in the outcome of surgery between the two groups. A good result was achieved in 36% of the normal small bowel transit time group compared with 33% in the abnormal group; the result was fair in 63% and 33%, and poor in 0% and 33%, respectively (P=NS). The small bowel transit study does not reliably predict the outcome of total abdominal colectomy in patients with colonic inertia.

Formalin instillation for hemorrhagic radiation proctitis.

Although formalin instillation has been proven to be an effective treatment of hemorrhagic radiation proctitis, different techniques with varying success rates have been reported. The aim of this study was to assess our experience with formalin instillation for the treatment of radiation proctitis. After Institutional Review Board approval, all patients who presented with radiation proctitis and were treated with 4% formalin instillation were identified from a prospective database. Techniques of instillation were as follows: a formalin-soaked sponge stick was applied via a proctoscope (SS) and placed at each quadrant with a mean contact of 2.5 minutes (range, 0.5-3 minutes), or the formalin solution was introduced through a proctoscope in aliquots for a total of 350 to 400 mL irrigation (IR), with a mean contact time of 30 seconds in each aliquot. The patients were divided into two groups according to the method of formalin instillation and their outcomes were compared. Between March 1995 and September 2003, 21 patients who underwent formalin treatment were identified: 17 patients were in the SS and 4 patients were in the IR group. The mean age was 74.8+/-6.4 years and 70.5+/-6.8 years and the male/female ratio was 16:1 and 3:1 in the SS and IR groups, respectively. Indications for radiation therapy were prostate cancer in 19 patients: 16 (95.1%) SS patients and 3 (75%) IR patients. Four (23.5%) patients in the SS group were receiving anticoagulants or antiplatelet medications before the procedure. The mean duration of bleeding before formalin instillation was 11.7 months (range, 2-48 months) in the SS and 10.5 months (range, 7-12 months) in the IR group. Sixteen (94.1%) patients in the SS and 4 (100%) in the IR group had previous treatments for radiation proctitis, including hydrocortisone enema, 5-aminosalicylate mesalamine, and endoscopic coagulation. Eight (47.1%) patients in the SS and 2 (50%) in the IR group received a preprocedural blood transfusion, and 1 patient in the SS group required a blood transfusion after the formalin instillation. This patient subsequently underwent restorative proctosigmoidectomy because of persistent bleeding. The mean length of the procedure was 27.1+/-10.8 minutes in the SS group and 22.5+/-6.5 minutes in the IR group. The bleeding was successfully stopped on the first attempt in 14 patients (82.4%) in the SS group and 3 (75%) in the IR group. The instillation was repeated in 1 patient (5.9%) in the SS group and in 1 (25%) in the IR group. Four patients (23.5%) in the SS group experienced rectal pain after the procedure. One patient (5.9%) developed a new onset of fecal incontinence, while another (5.9%) had anococcygeal pain accompanied by worsening of fecal incontinence. One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months). Formalin instillation is effective in controlling refractory hemorrhage secondary to radiation proctitis.

The efficacy of a nerve stimulator (Cavermap) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision.

PURPOSE: Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed. PATIENTS AND METHODS: Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. CaverMap was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeon's ability to localize the nerves and CaverMap to confirm this were evaluated. RESULTS: Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. CaverMap successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. CaverMap improved the identification rate in four of the remaining five patients. After proctectomy, CaverMap successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device. CONCLUSION: CaverMap may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation.

The association between late-onset fecal incontinence and obstetric anal sphincter defects.

HYPOTHESIS: Endoanal ultrasonographic results have demonstrated that clinically occult anal sphincter damage during vaginal delivery is common. This may or may not be associated with postpartum fecal incontinence (FI). Bayesian meta-analysis of the literature revealed that at least two thirds of obstetric sphincter disruptions are asymptomatic in the postpartum period. Women with postpartum asymptomatic sphincter damage may be at increased risk for FI with aging compared with those without sphincter injury. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: After excluding patients with other possible causes of FI, the histories of 124 consecutive women with late-onset FI after vaginal delivery were analyzed. MAIN OUTCOME MEASURES: Endoanal ultrasonographic findings, pudendal nerve terminal motor latency assessment, and anal manometric results. RESULTS: Eighty-eight women (71%) with a median of 3 vaginal deliveries had sphincter defects on endoanal ultrasonographic results. The mean incontinence score, squeeze and resting pressures, median age at last delivery, and median duration of FI were not significantly different between patients with and without sphincter defects. Pudendal neuropathy was more frequent in patients without sphincter defects (10 [30.3%], left side; 12 [36.4%], right side) than in patients with sphincter defects (12 [14.3%] and 16 [19.3%], respectively), with the difference nearly reaching statistical significance (P =.054 and P =.059, respectively). The median age at onset of FI in patients with a sphincter defect was 61.5 years vs 68.0 years in those without a sphincter defect, which was not statistically significant (P =.08). CONCLUSION: Analysis of the current patient population revealed that 88 women (71%) with late-onset FI after vaginal delivery had an anatomical sphincter defect. Thus, FI related to anal sphincter defects is likely to occur even in an elderly population who had experienced vaginal deliveries earlier in life.

New surgical options for fecal incontinence in patients with imperforate anus.

INTRODUCTION: Anorectal malformations are among the various etiologic factors causing fecal incontinence. Patients with imperforate anus are difficult to treat, specifically those with high lesions. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence. The aim of this study was to evaluate the results of these technologies in the treatment of patients with chronic fecal incontinence due to imperforate anus. METHODS: All patients with imperforate anus who had fecal incontinence and underwent either the artificial bowel sphincter procedure or the gracilis neosphincter procedure between February 1995 and December 2000 were evaluated. Preoperative and postoperative incontinence score (Cleveland Clinic Florida Incontinence Score; 0 = perfect continence; 20 = complete incontinence), quality of life, (Fecal Incontinence Quality of Life Scale, 29 items forming 4 scales), and manometric sphincter pressure results were compared. RESULTS: Eleven patients had artificial bowel sphincter and five had the gracilis neosphincter (one nonstimulated) procedure. There were 11 males and 5 females of a mean age of 25.3 (range, 15-45) years. The mean follow-up time was 1.7 years (5 months to 5.7 years). Eight (50 percent) complications occurred in six patients, including three with fecal impaction (all artificial bowel sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and two patients with concomitant wound infection (one gracilis neosphincter, one artificial bowel sphincter); no patients had the devices explanted. Fourteen patients had manometric data (10 artificial bowel sphincter and 4 gracilis neosphincter) available. The overall incontinence score decreased from a preoperative mean of 18.5 to a postoperative mean of 7.5 in the artificial bowel sphincter group (P < 0.01) and from 17.4 to 9.4 in the gracilis neosphincter group (P = 0.06). All four Fecal Incontinence Quality of Life scales increased in both the artificial bowel sphincter (lifestyle and depression/self-perception, P = 0.02; coping/behavior and embarrassment, P = 0.03) and the gracilis neosphincter (lifestyle and coping, P = 0.06; depression and embarrassment, P = 0.05) patients. As well, the mean resting and squeeze pressures increased with both techniques (artificial bowel sphincter: P = 0.008 and P = 0.02, respectively; gracilis neosphincter: P = 0.4 and P = 0.1, respectively). All results were statistically significant in the artificial bowel sphincter group. CONCLUSIONS: Artificial bowel sphincter and gracilis neosphincter are efficient methods to treat patients with imperforate anus. These techniques should be considered for patients with imperforate anus and severe fecal incontinence.

Outcome of patients with indeterminate colitis undergoing a double-stapled ileal pouch-anal anastomosis.

INTRODUCTION: The aim of this study was to assess the outcome of patients with indeterminate colitis undergoing double-stapled ileal pouch anal anastomosis. METHODS: A retrospective review of demographic, disease-related, and outcome variables of all patients undergoing double-stapled ileal pouch anal anastomosis from August 1988 to January 2000 was undertaken. All patients were evaluated using the validated American Society of Colon and Rectal Surgeons Fecal Incontinence Severity Index. Patients with familial adenomatous polyposis, those who had undergone pouch revision or had S-configured pouches, and patients with a follow-up of less than three months were excluded from analysis. RESULTS: Three hundred ninety-five patients underwent the double-stapled ileal pouch anal anastomosis; of these 303 patients were included for analysis. The mean duration of follow-up was 40 months. Fifty-six (18.1 percent) had a preoperative diagnosis of indeterminate colitis. Postoperatively, indeterminate colitis was diagnosed in 13 (4.3 percent), mucosal ulcerative colitis in 285 (94 percent), and Crohn's disease in 5 (1.6 percent). The overall complication rate was 37.7 percent, 60 percent, and (30.7) percent in patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Postoperative hemorrhage, abscess, and fistula occurred in 2.4 percent, 6.3 percent, and 3.9 percent, respectively, in patients with mucosal ulcerative colitis, and 0 percent, 15.3 percent, and 7.7 percent, respectively, in patients with indeterminate colitis. Small-bowel obstruction occurred in 8.5 percent, 20 percent, and 7.7 percent of patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Pouchitis occurred in 4.6 percent of patients with mucosal ulcerative colitis but in none of the patients with indeterminate colitis. Dysplasia of the anal transition zone was seen in one patient each with mucosal ulcerative colitis and indeterminate colitis. These patients had consistent follow-up and neither showed any sign of evolution to neoplastic disease. None of the patients with indeterminate colitis had a postoperative diagnosis of Crohn's disease during the follow-up period. Functional outcome was comparable in all three patient groups. CONCLUSION: The outcome of the double-stapled ileal pouch anal anastomosis in patients with indeterminate colitis is similar to that of patients with mucosal ulcerative colitis. Therefore, it is a safe option in patients with indeterminate colitis.

The efficacy of a nerve stimulator (CaverMap) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision.

PURPOSE: Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed. PATIENTS AND METHODS: Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. CaverMap was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeon's ability to localize the nerves and CaverMap to confirm this were evaluated. RESULTS: Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. CaverMap successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. CaverMap improved the identification rate in four of the remaining five patients. After proctectomy, CaverMap successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device. CONCLUSION: CaverMap may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation.

Histologic analysis of the irradiated anal sphincter.

PURPOSE: There is accumulating evidence, both quantitative and qualitative, that pelvic irradiation adversely affects anorectal function. However, histologic evidence of sphincter injury has not been demonstrated. This study was designed to perform histologic assessment of collagen deposition and nerve alteration in the internal anal sphincters of rectal cancer patients who underwent abdominoperineal resection after adjuvant chemoradiation therapy and to correlate the degree of histologic changes with the time interval between chemoradiotherapy and abdominoperineal resection. METHODS: Anal canal specimens were prospectively collected in patients undergoing abdominoperineal resection. Representative slides were cut transversely at the level of the dentate line. Using trichrome and S-100 protein staining, a single pathologist blinded to the patients' treatment assessed collagen deposition and nerve fiber densities in the internal anal sphincter, respectively. RESULTS: Twelve patients received radiation for rectal cancer (chemoradiotherapy group) and six were treated by surgery alone, including four patients with rectal cancer (1 leiomyosarcoma) and two with Crohn's disease (control group). There was a trend toward increased fibrosis (replacement of >10 percent of normal structures by collagen) and nerve density in the chemoradiotherapy group compared with the control group (P = 0.08 and P = 0.05, respectively). Nerve density significantly increased as chemoradiotherapy to abdominoperineal resection interval increased (P = 0.04). CONCLUSIONS: Pelvic irradiation results in damage to the myenteric plexus of the internal anal sphincter of patients with rectal cancer; these alterations seem to be time-dependent. A trend toward increased collagen deposition also was observed. Together, these results provide a morphologic basis, which concurs to previously described physiologic and clinical alterations in the anal sphincter of patients irradiated for rectal cancer.

Colorectal cancer screening: do they practice what they preach?

INTRODUCTION: Compliance for voluntary colorectal cancer (CRC) screening reported by the American Society of Colon and Rectal Surgeons (ASCRS) is>85%. This high rate is assumed to be the result of heightened awareness of CRC. The purpose of the present paper was to determine if observed participation rates in the USA are the result of increased awareness of CRC alone. METHODS: Postal survey of Colorectal Surgical Society of Australia (CSSA). RESULTS: A response rate of 65% (52\80) was observed. As in the ASCRS, the majority of members support screening (94%); but 4% (2\52) reported that they do not advocate CRC screening, which was lower than that observed in the ASCRS survey (P = 0.03). A total of 94% support screening of baseline risk (BLR) patients at age 50 or less. Support was similar for annual fecal occult blood testing (FOBT; CSSA 54% vs ASCRS 56%, P = NS) for patients with BLR, but much less support for colonoscopy every 10 years (CSq10) was observed (CSSA 31% vs ASCRS 68%, P < 0.01). Similar to the ASCRS, CS every 5 years (CSq5) was the most common strategy advocated to patients with a family history of polyps (CSSA 75% vs ASCRS 78%, P = NS) and cancer (CSSA 94% vs ASCRS 94%, P = NS), respectively. A total of 25% (13\52) of CSSA members report participating in CRC screening, compared to the 55% reported by the ASCRS (P < 0.01). As in the ASCRS, CSq5 (69%) was the most common form of screening undergone. None of the CSSA members were being screened with more than one test, compared to the 46% reported by the ASCRS (P < 0.01). Of those who had not been screened, 82%(31\38) reported that they do plan to undergo CRC screening compared to 99% reported by the ASCRS (P < 0.05). CONCLUSION: Screening compliance is significantly higher in the ASCRS than in the CSSA. Awareness of CRC is not the only obstacle to improving screening compliance.

Colon and rectal cancer in the elderly. High incidence of asymptomatic disease, less surgical emergencies, and a favorable short-term outcome.

BACKGROUND: This is a retrospective study aimed to report short-term outcome among patients age > or =70 years surgically treated for colorectal cancer. METHODS: All patients with the discharge diagnosis of colon and rectal cancer at St. Louis University Hospital from 1992 to 2002 were reviewed. Patients were assessed as to demographics, presenting symptoms, therapy, surgical morbidity and mortality. RESULTS: One hundred eighty-one patients age > or =70 years with colorectal cancer were identified. The mean age was 78 years; 107/181 (59%) were females. Rectal bleeding and change in bowel habits were the most common presenting symptoms. Fifty-four out of 181 (30%) were asymptomatic at diagnosis. The diagnosis was made by colonoscopy in 75% of the patients. One hundred forty-three out of 181 (79%) had colon cancer; 38/181 (21%) had rectal cancer. Fourteen out of 181 (8%) did not undergo surgery. Twenty-two out of 181 (12%) were operated on as a surgical emergency. ASA classification was I-II in 52%, III in 34%, and IV-V in 14%. Nineteen out of 38 (50%) with rectal cancer underwent a sphincter-preserving procedure. Overall, there was a 29% major morbidity from surgery. Thirty-day mortality was 11% (21 deaths). Only the development of a postoperative complication predicted mortality. CONCLUSIONS: Elderly patients tolerate surgery well for colon and rectal cancer in the short-term. Many patients are asymptomatic at diagnosis. Surgical emergencies are few and patients have a favorable stage of disease. This data supports aggressive detection of colorectal cancer in asymptomatic elderly patients who may harbor occult colorectal cancer.

Endorectal advancement flap: are there predictors of failure?

PURPOSE: The management of complex perianal fistulas with endorectal advancement flap is aimed at avoiding the risk of sphincter injury associated with traditional surgical methods. Long-term follow-up is required to assess the recurrence and continence outcomes of this procedure. The aim of this study was to review our experience with endorectal advancement flap in the treatment of complex perianal fistulas and to define the predictors of successful healing. METHODS: A retrospective chart review of all patients who underwent endorectal advancement flap for complex perianal fistulas between 1988 and 2000 was performed. Follow-up was established by telephone interview. RESULTS: One hundred six consecutive endorectal advancement flap procedures were performed on 94 patients (94.4 percent). There were 56 females (59.6 percent). Mean age was 41.6 (range, 18-76) years. Cryptoglandular disease was the most common cause of fistula (n = 41, 43.6 percent), followed by Crohn's disease (n = 28, 29.8 percent). At a mean follow-up of 40.3 (range, 1-149) months, the procedure was successful in 56 (59.6 percent) of 94 patients. Twelve patients underwent repeat surgery with the same technique because of initial failure, 8 of whom eventually healed. Crohn's disease was associated with a significantly higher recurrence rate (57.1 percent) when compared with fistulas in patients without Crohn's disease (33.3 percent, P< 0.04). Prior attempts at repair of the fistula were not associated with less favorable outcome of the procedure (P = 0.5). Recurrence was not associated with the type of fistula, origin, preoperative steroid use, postoperative bowel confinement, use of postoperative antibiotics, or creation of a diverting stoma. The median time to recurrence was 8 (range, 1-156) weeks; there was no postoperative mortality. Two patients had postoperative bleeding, one requiring resuture of the flap on the first postoperative day. Recurrences were observed in 15.7 percent of the patients 3 or more years after the repair. In 8 patients (9 percent), continence deteriorated after the endorectal advancement flap, a more common finding in patients who had undergone previous surgical repairs (P < 0.02). CONCLUSION: The success rate of endorectal advancement flap for complex perianal fistulas is modest. Failure is mainly correlated with the presence of Crohn's disease.

The procon incontinence device: a new nonsurgical approach to preventing episodes of fecal incontinence.

OBJECTIVES: Treatment of severe fecal incontinence (FI) is essentially surgical. However, patients in whom surgery has failed, those who have high operative risks, and those who refuse to undergo surgery are often condemned to living with this embarrassing condition. The Procon incontinence device, a relatively simple, nonsurgical device, may represent a good solution in preventing episodes of FI, thus improving quality of life in these individuals. This device consists of a disposable, pliable rubber catheter with an infrared photo-interrupter sensor and flatus vent holes on the distal tip that is connected to a pager (or "beeper"). The catheter is inserted in the rectum and held in place by a 20-cc capacity cuff, which acts as a temporary mechanical barrier to stool leakage. Stool entering the rectum is sensed by the photo-interrupter sensor, which then alerts the patient to an imminent bowel movement. Voluntary evacuation is accomplished by deflating the balloon and removing the catheter. The aim of this study was to evaluate the efficacy, reliability, and safety of the Procon device in a group of patients with FI. METHODS: Patients with significant FI who had undergone anorectal manometry, ultrasound, and electromyography with pudendal nerve terminal motor latency assessment were prospectively entered into this study. The Procon device was used for 14 consecutive days. A quality of life diary and daily log of bowel activity and incontinent episodes were completed before and after the end of the study. RESULTS: Seven patients (five female and two male) with a mean age of 72.7 yr (range 39-81 yr) were evaluated. Etiology of incontinence included idiopathic in four patients, sphincter defect in two, and neurological disorder in one patient. There was an overall significant improvement in the quality of life (p < 0.05) and a significant reduction in incontinence scores with the Procon device (p < 0.05). CONCLUSION: The Procon is a unique, safe, and promising device that is able to prevent episodes of FI without the need for surgery, thereby improving quality of life. Its role includes use in patients with severe FI who are unfit to undergo surgery, those in whom previous surgical treatments have failed, or those who do not wish to undergo surgery.

Long-term efficacy of dynamic graciloplasty for fecal incontinence.

PURPOSE: Patients with end-stage fecal incontinence in whom all standard medical and surgical treatment has failed or is not expected to be effective can be treated by dynamic graciloplasty. The aim of this study was to review the long-term efficacy data. METHODS: Success was defined as a greater than 50 percent decrease in the frequency of incontinent episodes. Measured physiologic parameters included enema retention time and the difference in resting and squeezing pressures with and without stimulation. Measured quality-of-life parameters included the Medical Outcomes Study Short Form 36 Health Status Questionnaire, a Fecal Incontinence TyPE Specification, the Zung Self-Rating Depression Scale, the "state" portion of the State-Trait Anxiety Inventory, and the Visual Analog Scale, which were administered at baseline and through follow-up. Independent monitors collected data as part of a multicenter trial for patients who underwent dynamic graciloplasty from May 1993 to November 1999. RESULTS: There were 129 patients entered in the study, 115 of whom met eligibility criteria and were included in the efficacy outcome analysis. Twenty-seven patients entered the study with a preexisting functioning stoma; the remaining 88 patients did not have a functioning stoma at the time of enrollment. Success was achieved in 62 percent of nonstoma patients at 12 months; these results were sustained at 18-month and 24-month follow-up assessments (55 and 56 percent, respectively). The success rate in the stoma patients increased from 37.5 percent (9 of 24 patients) at 12 months to 62 percent (13 of 21 patients) at 18 months and was 43 percent at 24 months (9 of 21 patients), which reflects the increased number of patients whose stomas were closed. Although the measured physiologic continence parameters generally improved, these changes did not correlate with continence outcome. The group of patients (stoma and nonstoma) who underwent dynamic graciloplasty showed statistically significant improvements in quality of life as measured by Medical Outcomes Study Short Form 36 physical function (P = 0.006) and social functioning (P = 0.02) assessment. CONCLUSIONS: Dynamic graciloplasty was successful in the majority of patients with end-stage fecal incontinence. This result was usually achieved by 12 months after surgery in patients who did not have stomas and by 18 months in patients who had stomas at the time of dynamic graciloplasty surgery. These various improvements conferred by dynamic graciloplasty persisted during the two-year follow-up.