Overuse of Proximal Fecal Diversion in Colorectal Surgery.

Many surgeons tend to overuse proximal fecal diversion in the setting of colonic surgery. The decision to proximally divert an anastomosis should be made with careful consideration of the risks and benefits of proximal diversion. Proximal diversion does not decrease the rate of anastomotic leak, but it does decrease the severity of leaks. Anastomotic height for low pelvic anastomoses, hemodynamic instability, steroid use, male sex, obesity, malnutrition, smoking, and alcohol abuse increase the rate of anastomotic leak. Biologics, most immunosuppressive agents, unprepped colons, and radiation for rectal cancer do not contribute to increased rates of anastomotic leak. Proximal fecal diversion creates additional potential morbidity, higher rates of readmission, and need for a subsequent hospitalization and operation for reversal. Additionally, diverted patients have higher rates of anastomotic stricture and delayed recognition of chronic leaks. These downsides to diversion must be weighed with a patient's perceived ability to handle the physiologic stress and consequences of a severe leak if reoperation is required. When trying to determine which patients can handle a leak, the modified frailty index can help to objectively determine a patient's risk for increased rate of morbidity and failure to rescue in the event of a leak. While proximal diversion is still warranted in many cases, we find that certain clinical scenarios often lead to overuse of proximal diversion. The old surgical adage "If you are considering diverting, you should probably do it" should be tempered by an understanding of the risk and benefits of diversion.

Liposomal Bupivacaine Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Resections: A Single-Institution Randomized Controlled Trial.

BACKGROUND: Transversus abdominis plane blocks improve postoperative pain after colon and rectal resections, but the benefits of liposomal bupivacaine use for these blocks have not been clearly demonstrated. OBJECTIVE: This study aimed to determine whether using liposomal bupivacaine in transversus abdominis plane blocks improves postoperative pain and reduces opioid use after colorectal surgery compared to standard bupivacaine. DESIGN: This study was a single-blinded, single-institution, prospective randomized controlled trial comparing liposomal bupivacaine to standard bupivacaine in transversus abdominis plane blocks in patients undergoing elective colon and rectal resections. SETTINGS: This study was conducted at a single-institution academic medical center with 6 staff colorectal surgeons and 2 colorectal surgery fellows. PATIENTS: Ninety-six patients aged 18 to 85 years were assessed for eligibility; 76 were included and randomly assigned to 2 groups of 38 patients. INTERVENTIONS: Patients in the experimental group received liposomal bupivacaine transversus abdominis plane blocks, whereas the control group received standard bupivacaine blocks. MAIN OUTCOME MEASURES: The primary outcome was maximum pain score on postoperative day 2. Secondary outcomes included daily maximum and average pain scores in the 3 days after surgery, as well as daily morphine milligram equivalent use and length of hospital stay. RESULTS: Patients receiving liposomal bupivacaine blocks had lower maximum pain scores on the day of surgery (mean, 6.5 vs 7.7; p = 0.008). No other difference was found between groups with respect to maximum or average pain scores at any time point postoperatively, nor was there any difference in morphine milligram equivalents used or length of stay (median, 3.1 d). LIMITATIONS: This was a single-institution study with only patients blinded to group assignment. CONCLUSIONS: Liposomal bupivacaine use in transversus abdominis plane blocks for patients undergoing laparoscopic colorectal resections does not seem to improve postoperative pain, nor does it reduce narcotic use or decrease length of stay. Given its cost, use of liposomal bupivacaine in transversus abdominis plane blocks is not justified for colon and rectal resections. See Video Abstract at http://links.lww.com/DCR/B979 . CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Identifier: NCT04781075. BLOQUEOS TAP DE BUPIVACANA LIPOSOMAL EN RESECCIONES COLORRECTALES LAPAROSCPICAS UN ENSAYO CONTROLADO ALEATORIO DE UNA SOLA INSTITUCIN: ANTECEDENTES:Los bloqueos del plano transverso del abdomen, mejoran el dolor posoperatorio después de las resecciones de colon y recto, pero los beneficios del uso de bupivacaína liposomal para estos bloqueos, no se han demostrado claramente.OBJETIVO:Investigar la eficacia de la inyección con tejido adiposo autólogo recién recolectado en fístulas anales criptoglandulares complejas.DISEÑO:Ensayo controlado, aleatorio, prospectivo, simple ciego, de una sola institución, que compara la bupivacaína liposomal con la bupivacaína estándar en bloqueos del plano transverso del abdomen, en pacientes sometidos a resecciones electivas de colon y recto. Identificador de ClinicalTrials.gov : NCT04781075.ENTORNO CLINICO:Centro médico académico de una sola institución con seis cirujanos de plantilla y becarios de cirugía colorrectal.PACIENTES:Se evaluó la elegibilidad de 96 pacientes de 18 a 85 años; 76 fueron incluidos y aleatorizados en dos grupos de 38 pacientes.INTERVENCIONES:Los pacientes del grupo experimental recibieron bloqueos del plano transverso del abdomen con bupivacaína liposomal, mientras que el grupo de control recibió bloqueos de bupivacaína estándar.PRINCIPALES MEDIDAS DE VALORACION:El resultado primario fue la puntuación máxima de dolor en el segundo día posoperatorio. Los resultados secundarios incluyeron las puntuaciones máximas y medias diarias de dolor en los 3 días posteriores a la cirugía, así como el uso diario equivalente en miligramos de morfina y la duración de la estancia hospitalaria.RESULTADOS:Los pacientes que recibieron bloqueos de bupivacaína liposomal, tuvieron puntuaciones máximas de dolor más bajas, el día de la cirugía (media 6,5 frente a 7,7, p = 0,008). No hubo ninguna otra diferencia entre los grupos con respecto a las puntuaciones de dolor máximas o promedio en cualquier momento después de la operación, ni hubo ninguna diferencia en los equivalentes de miligramos de morfina utilizados o la duración de la estancia (mediana de 3,1 días).LIMITACIONES:Estudio de una sola institución con cegamiento de un solo paciente.CONCLUSIONES:El uso de bupivacaína liposomal en bloqueos del plano transverso del abdomen, para pacientes sometidos a resecciones colorrectales laparoscópicas, no parece mejorar el dolor posoperatorio, ni reduce el uso de narcóticos ni la duración de la estancia hospitalaria. Dado su costo, el uso de bupivacaína liposomal en bloqueos TAP no está justificado para resecciones de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B797 . Traducción Dr. Fidel Ruiz Healy.

Clopidogrel bisulfate (Plavix) does not increase bleeding complications in patients undergoing rubber band ligation for symptomatic hemorrhoids.

BACKGROUND: The incidence of postprocedural bleeding in patients undergoing rubber band ligation (RBL) for symptomatic internal hemorrhoids while taking clopidogrel bisulfate is unknown. To determine the postprocedural bleeding risk of RBL for patients taking clopidogrel compared with age- and sex-matched controls. MATERIALS AND METHODS: This is a retrospective case-controlled cohort study analyzing data from 2005 to 2013 conducted at a single tertiary care academic center. The study included a total of 80 rubber bands placed on 41 patients taking clopidogrel bisulfate and 72 bands placed on 41 control patients not taking clopidogrel matched for age and sex. The 30-d rates of significant and insignificant bleeding events after RBL were recorded. A bleeding event was considered significant if the patient required admission to the hospital, transfusion of blood products, or additional procedures to stop the bleeding. Insignificant bleeding was defined as passage of blood or clots per rectum with spontaneous cessation and no need for additional intervention. RESULTS: There was no significant difference in the number of bleeding events per band placed in the clopidogrel group when compared with the control group (3.75% versus 2.78%, P = 0.7387). The rate of significant (2.5% versus 1.39%, P = 0.6244) and insignificant bleeding events (1.25% versus 1.39%, P = 0.9399) was also similar between the two groups. Two significant bleeding events occurred in the clopidogrel group requiring intervention: cauterization in one patient and colonoscopy and transfusion in the other. CONCLUSIONS: The risk of a bleeding complication after RBL for hemorrhoids does not appear to be increased in patients taking clopidogrel. Our results support the practice of continuing clopidogrel bisulfate in the periprocedural period as the associated risk of thrombosis is greater than the risk of bleeding.

Morbidity Following Coloanal Anastomosis: A Comparison of Colonic J-Pouch vs Straight Anastomosis.

BACKGROUND: Low rectal tumors are often treated with sphincter-preserving resection followed by coloanal anastomosis. OBJECTIVE: The purpose of this study was to compare the short-term complications following straight coloanal anastomosis vs colonic J-pouch anal anastomosis. DESIGN: Patients were identified who underwent proctectomy for rectal neoplasia followed by coloanal anastomosis in the 2008 to 2013 American College of Surgeons National Surgical Quality Improvement Program database. Demographic characteristics and 30-day postoperative complications were compared between groups. SETTINGS: A national sample was extracted from the American College of Surgeons National Surgical Quality Improvement Project database. PATIENTS: Inpatients following proctectomy and coloanal anastomosis for rectal cancer were selected. MAIN OUTCOME MEASURES: Demographic characteristics and 30-day postoperative complications were compared between the 2 groups. RESULTS: One thousand three hundred seventy patients were included, 624 in the straight anastomosis group and 746 in the colonic J-pouch group. Preoperative characteristics were similar between groups, with the exception of preoperative radiation therapy (straight anastomosis 35% vs colonic J-pouch 48%, p = 0.0004). Univariate analysis demonstrated that deep surgical site infection (3.7% vs 1.4%, p = 0.01), septic shock (2.25% vs 0.8%, p = 0.04), and return to the operating room (8.8% vs 5.0%, p = 0.0006) were more frequent in the straight anastomosis group vs the colonic J-pouch group. Major complications were also higher (23% vs 14%, p = 0.0001) and length of stay was longer in the straight anastomosis group vs the colonic J-pouch group (8.9 days vs 8.1 days, p = 0.02). After adjusting for covariates, major complications were less following colonic J-pouch vs straight anastomosis (OR, 0.57; CI, 0.38-0.84; p = 0.005). Subgroup analysis of patients who received preoperative radiation therapy demonstrated no difference in major complications between groups. LIMITATIONS: This study had those limitations inherent to a retrospective study using an inpatient database. CONCLUSION: Postoperative complications were less following colonic J-pouch anastomosis vs straight anastomosis. Patients who received preoperative radiation had similar rates of complications, regardless of the reconstructive technique used following low anterior resection. See Video Abstract at http://links.lww.com/DCR/A468.

Interval Colorectal Cancers at Ochsner Medical Center: Where Do We Stand?

BACKGROUND: An interval colorectal cancer is a cancer diagnosed prior to the recommended follow-up time from a previously negative colonoscopy. These cancers are thought to arise from a rapidly growing cancer, missed cancer, or incompletely resected adenomas. Our study aimed to identify interval cancers diagnosed during a 4-year period and to identify any potential risk factors associated with these cancers. Secondly, we compared our interval colorectal cancer rate with other published rates. METHODS: Our population included all patients who underwent colonoscopy for any indication between August 1, 2010 and July 31, 2014 (n=28,794), excluding individuals <18 years and patients with a history of inflammatory bowel disease, previously diagnosed colorectal cancer, or known hereditary cancer syndrome. Using a retrospective review of our institution's electronic medical record and data from the Louisiana Tumor Registry, we identified patients who were diagnosed with colorectal cancer. From these individuals, we reviewed and selected those who met the criteria for interval cancers. RESULTS: We identified 20 interval cancers during the 4-year study period. Based on the total number of index colonoscopies performed during the time period, our overall incidence rate was 0.07%. Approximately 1 interval cancer was diagnosed per 1,400 colonoscopy examinations. Our occurrence rate of 0.28 cases per 1,000 person-years of observation was less than or similar to the rates reported in other studies. CONCLUSION: Our study demonstrated that our institution has a low incidence of interval cancers, supporting the effectiveness of our cancer screening program. To further minimize interval colorectal cancers, we recommend the documentation and reporting of endoscopy quality measures, as well as close follow-up intervals or alternate examinations for patients who have poor bowel preparation or incomplete/difficult examinations.

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

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

Current State of Colorectal Surgery Training: A Survey of Program Directors, Current and Recently Matched Colorectal Residents, and Recent Colorectal Graduates.

BACKGROUND: Colorectal residency has become one of the more competitive postgraduate training opportunities; however, little information is available to guide potential applicants in gauging their competitiveness. OBJECTIVE: The aim of this study was to identify the current trends colorectal residency training and to identify what factors are considered most important in ranking a candidate highly. We hypothesized that there was a difference in what program directors, current and recently matched colorectal residents, and recent graduates consider most important in making a candidate competitive for a colorectal residency position. DESIGN: Three 10-question anonymous surveys were sent to 59 program directors, 87 current and recently matched colorectal residents, and 119 recent graduates in March 2015. SETTINGS: The study was conducted as an anonymous internet survey. MAIN OUTCOME MEASURES: Current trends in applying for a colorectal residency, competitiveness of recent colorectal residents, factors considered most important in ranking a candidate highly, and what future colorectal surgeons can expect after finishing their training were measured. RESULTS: The study had an overall response rate of 43%, with 28 (47%) of 59 program directors, 46 (53%) of 87 current and recently matched colorectal residents, and 39 (33%) of 119 recent graduates responding. The majority of program directors felt that a candidate's performance during the interview process was the most important factor in making a candidate competitive, followed by contact from a colleague, letters of recommendation, American Board of Surgery In-Training Exam scores, and number of publications/presentations. The majority of current and recently matched colorectal residents felt that a recommendation/telephone call from a colleague was the most important factor, whereas the majority of recent graduates favored letters of recommendation as the most important factor in ranking a candidate highly. LIMITATIONS: Limitations to the study include its small sample size, selection bias, responder bias, and misclassification bias. CONCLUSIONS: There are differences in what program directors and current/recent residents consider most important in making an applicant competitive for colorectal residency.

Restorative proctocolectomy: the current ochsner experience.

BACKGROUND: Restorative proctocolectomy with an ileal pouch-anal anastomosis is a technically demanding procedure to treat ulcerative colitis and familial adenomatous polyposis. Since its initial description almost 30 years ago, the operation has undergone technical and perioperative modifications to improve the patient's experience. METHODS: We performed a retrospective review of the records of patients undergoing restorative proctocolectomy at the Ochsner Clinic Foundation Hospital from 2008 to 2012 and compared data from that period to data from 1989-1995 (prior to laparoscopic pouch surgery) to determine factors associated with patient outcome. RESULTS: Ileal pouch-anal procedures were performed in 77 patients. The 30 male and 47 female patients ranged in age from 13 to 63 years (mean, 34.5 years). The indications for the procedure were ulcerative colitis in 62 patients, polyposis coli in 12 patients, and Crohn disease in 3 patients. Forty patients (52%) had laparoscopic-assisted procedures. The overall hospital length of stay for pouch creation averaged 6.9 days (range 3-29) and for ileostomy closure averaged 4.3 days (range 1-15). No perioperative deaths occurred within 30 days. Complications occurred in 37.7% of patients. Compared to a previous report of 72 patients from 1989 to 1995, the recent group had more laparoscopic procedures, shorter hospital stays, a smaller percentage of 3-stage procedures, and fewer general and pouch-related complications. Pouch failures were similar for both groups. CONCLUSION: Advances in operative techniques and perioperative management have improved the outcome of restorative proctocolectomies.

Sexually transmitted and anorectal infectious diseases.

Sexually transmitted diseases (STDs) are common and they can involve the anus and rectum in both men and women. In this article, the main bacterial and viral STDs that affect the anus and rectum are discussed, including their prevalence, presentation, and treatment.

Intramural colonic splenosis: a rare case of lower gastrointestinal bleeding.

BACKGROUND: A 41-year-old man had left upper quadrant abdominal pain, constipation, and melena. About 6 years previously, he received a single gunshot wound to the abdomen, which required partial gastrectomy and small bowel resection. He subsequently developed bleeding gastric varices for which he underwent a splenectomy 2 years before the current admission. DISCUSSION: A CT scan identified a 6.5 × 2.5 cm left upper quadrant mass. Upper endoscopy was unremarkable, but on colonoscopy, a 3-cm polypoid mass partially obstructed the descending colon. A left hemicolectomy was performed with a primary colonic anastomosis and incidental appendectomy. The mass involved the muscularis of the colon and caused ulceration of the mucosa was ectopic hyperplasic splenic tissue, indicating intramural colonic splenosis. We hypothesize that after the patient's splenectomy, a colonic focus of heterotrophic spleen became hyperplastic and led to a clinically apparent lesion.

Endoscopic treatment for lower gastrointestinal bleeding.

Lower gastrointestinal bleeding is common and can result from several colonic causes including diverticulosis, arteriovenous malformations, ischemia, inflammatory bowel disease, infectious colitis, neoplasm, postpolypectomy, and anastomotic and radiation proctitis. Following resuscitation and evaluation, colonoscopy can be used for diagnosis and treatment. Most physicians prescribe a bowel preparation for their patients. Therapeutic options include injection, coagulation (monopolar or bipolar cautery, argon plasma coagulator), and mechanical (clips, bands, detachable loops) devices.

Variations in perioperative steroid management among surgical subspecialists.

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

The medical and nonoperative treatment of diverticulitis.

The success of medical management for diverticular disease depends on the patient's presentation and degree of response to treatment. The patient's presentation can be grouped into categories using classification systems such as the modified Hinchey system. Clinical presentation and diagnostic studies help to group patients. Mild disease can often be managed with oral antibiotics as an outpatient; more severe disease requires hospitalization, bowel rest, and intravenous antibiotics. Interventions such as percutaneous drainage of associated abscesses may allow successful medical management. Probiotics and antiinflammatories may have a supportive role. Indications for elective resections are discussed.

Rectal prolapse: a 10-year experience.

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

Evaluation and management of gastrointestinal bleeding.

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

The importance of colonoscopy in colorectal surgeons' practices: results of a survey.

PURPOSE: The role of colonoscopy in the prevention of colorectal cancer has been accepted, not only by the medical community but by the federal government as well. This study sought to document the current role of colonoscopy in the practices of colorectal surgeons. METHODS: A survey was mailed to members of The American Society of Colon and Rectal Surgeons detailing the scope of colonoscopy in their practices. RESULTS: Surveys were mailed to 1,800 members of The American Society of Colon and Rectal Surgeons; responses were received from 778 (43.2 percent). The mean age was 48 +/- 10 (range, 27-79) years; the mean number of years in practice was 14 +/- 10 (range, 0.2-48). The majority of respondents (91 percent) were male. Responses were received from 47 U.S. states and 30 foreign countries. Seventy-four respondents (9.5 percent) reported not performing colonoscopy; the most common reason cited was "referring physicians' preference" (45 percent). Seven-hundred four respondents (90.5 percent) reported performing colonoscopy as part of their clinical practice and reported an average of 41 +/- 41 colonoscopies in the last month (range, 0-635) and 457 +/- 486 in the last year (range, 2-7,000). Colonoscopy accounted for 23 +/- 16 percent of responding physicians' clinical time (range, 1-100 percent) and 27 +/- 19 percent of total charges (range, 0-100 percent). Nearly all respondents (97 percent) anticipated maintaining or increasing their volume of colonoscopy in the coming year. Eighty-four percent of respondents reported receiving some or all of their training in colonoscopy during a colon and rectal surgery fellowship. More than one-half of respondents (55 percent) believed that there should be more of an emphasis on colonoscopy on the American Board of Colon and Rectal Surgery board examination, and 81 percent believed that the annual meeting of The American Society of Colon and Rectal Surgeons should include lectures and/or courses covering colonoscopy. CONCLUSIONS: Colonoscopy plays a major role in the practices of colorectal surgeons across the world, accounting for approximately one-quarter of clinical time and total charges. Based on the expectation that this trend will continue, The American Society of Colon and Rectal Surgeons needs to aggressively support its members not only in the technical aspects of colonoscopy but also in the practice management issues.

Postoperative enterocutaneous fistula: when to reoperate and how to succeed.

An enterocutaneous fistula (ECF) is a potentially catastrophic postoperative complication. Although the morbidity and mortality associated with ECF have decreased over the past 50 years with modern medical and surgical care, the overall mortality is still surprisingly high, up to 39% in recent literature. It seems prudent, then, for every surgeon to have a thorough grasp of optimal treatment strategies for ECF to minimize their patients' mortality. Ultimately, the algorithm must begin with prevention. Once an ECF is diagnosed, the first step is to resuscitate and treat sepsis. The second is to control fistula output. The third step is to optimize the patient medically and nutritionally. The last step is definitive restoration of gastrointestinal continuity when necessary. Special mention is given in this article to exceptionally refractory fistulas such as those arising in the presence of inflammatory bowel disease and irradiated bowel. This plan gives a framework for the difficult task of successfully treating the postoperative ECF with a multidisciplinary approach.

Local recurrence, distant recurrence and survival of rectal cancer.

PURPOSE: To assess our institution's ability to minimize local and distant recurrence with a preference for sphincter preserving surgery in the management of rectal cancer. METHODS: A retrospective analysis of all patients treated between 1982 and 1998. Patients with Stage 0 (AJCC) disease and those treated for palliation were not included. Clinical and pathologic stage, operation type, adjuvant therapy, recurrence, and survival were compared. Kaplan-Meier analysis was also performed. RESULTS: Rectal cancer was identified in 332 patients (mean follow-up: 5.5 years). One hundred and seventy-three patients (52.1%) underwent low anterior resection, while 107 patients (32.2%) required abdominoperineal resection, 6 patients (1.8%) required exenteration to control disease, and 46 (13.9%) patients were treated with local excision. Of the 332 patients, 63 (19.0%) received adjuvant radiotherapy alone, 85 (25.6%) received combination chemoradiotherapy, and 4 (1.2%) received chemotherapy. Sphincter preserving procedures were used more frequently in the later half of the experience. Local/regional recurrences occurred in 5 patients (3.3%) treated with adjuvant therapy, and in 16 patients (8.9% of total) who did not receive adjuvant therapy (p=0.02, Chi-square test) although the total risk of recurrence (local and/or distant) was not different (30.2% vs. 27.7%, p=0.54). The actuarial rate of local recurrence (regardless of adjuvant therapy) for all stages was 7% at 5 years, and the risk of any recurrence (local or distant) was 21.1% at 5 years. Cancer specific 5-year survival was 77% overall. CONCLUSIONS: In rectal cancer, the therapeutic objectives are to control disease, limit recurrence, and preserve sphincter function; these goals were met for many patients at this institution. These data compare favorably with the current literature. Careful surgical technique and adjuvant therapy can allow successful treatment, even of advanced rectal cancers.

Continent ileostomy: current experience.

PURPOSE: This study was designed to review our recent experience with continent ileostomies and evaluate patient outcomes. METHODS: Retrospective chart reviews and phone interviews of patients who underwent a continent ileostomy operation from 1993 to 2003 at the Ochsner Clinic Foundation were performed. RESULTS: Twenty-four patients (19 females; age range, 22-73 years) had construction of continent ileostomies (modified Kock pouch). There were no intraoperative mortalities or stoma-related deaths. The mean operating room time for primary construction was 3.9 +/- 0.57 hours with a mean length of stay of 7 +/- 2 days. The average follow-up period was 66 (range, 6-134) months. The most common underlying indication for the construction of a continent ileostomy was ulcerative colitis (71 percent). Thirteen patients had a continent ileostomy created for conversion of a Brooke ileostomy and seven for a failed ileoanal pouch. Other indications included colonic inertia and incontinence in three patients and one patient who had failed multiple operations for Hirschsprung's disease. A total of 28 revisions were performed in 14 patients (58 percent). Six patients required multiple procedures. Operative revisions included 12 skin level revision for stenosis, 11 operations for valve repairs, and 1 each for peristomal hernia repair, stomal relocation, and pouch repair for fistulas. Two patients had their pouches removed (Crohn's disease and inability to manage pouch). The need for revision by 12 months was 29 percent, and the average time period before the first revision was 24 months (range, 4 days to 109 months). The overall failure rate (converted to conventional ileostomy) was only 8.3 percent. Ninety percent of the patients have continent pouches and are satisfied with their pouch function. CONCLUSIONS: Continent ileostomies continue to have a high rate of reoperations, reasonable functional results, and are a viable option for failed ileal pouch-anal pouch patients. Surgeons electing to perform continent ileostomies must carefully select their patients and advise them of the high potential for reoperations. Despite a high reoperation rate, patients are pleased with their continent ileostomies.