Effectiveness of Sodium Picosulfate/Magnesium Citrate (PICO) for Colonoscopy Preparation

PURPOSE: Bowel preparation with sodium phosphate was recently prohibited by the U.S. Food and Drug Administration. Polyethylene glycol (PEG) is safe and effective; however, it is difficult to drink. To identify an easy bowel preparation method for colonoscopy, we evaluated three different bowel preparation regimens regarding their efficacy and patient satisfaction. METHODS: In this randomized, comparative study, 892 patients who visited a secondary referral hospital for a colonoscopy between November 2012 and February 2013 were enrolled. Three regimens were evaluated: three packets of sodium picosulfate/magnesium citrate (PICO, group A), two packets of PICO with 1 L of PEG (PICO + PEG 1 L, group B), and two packets of PICO with 2 L of PEG (PICO + PEG 2 L, group C). A questionnaire survey regarding the patients' preference for the bowel preparation regimen and satisfaction was conducted before the colonoscopies. The quality of bowel cleansing was scored by the colonoscopists who used the Aronchick scoring scale and the Ottawa scale. RESULTS: The patients' satisfaction rate regarding the regimens were 72% in group A, 64% in group B, and 45.9% in group C. Nausea and abdominal bloating caused by the regimens were more frequent in group C than in group A or group B (P < 0.01). Group C showed the lowest preference rate compared to the other groups (P < 0.01). Group C showed better right colon cleansing efficacy than group A or group B. CONCLUSION: Group A exhibited a better result than group B or group C in patient satisfaction and preference. In the cleansing quality, no difference was noted between groups A and C.

Application of BMS(TM) Avoids a Defunctioning Colostomy in the Treatment of Fournier's Gangrene

PURPOSE: Recently developed BMS(TM) (Zassi Bowel Management System(TM): Hollister Inc., Illinois, USA) can provide effective nonsurgical fecal diversion without the risks associated with colostomy creation and subsequent closure. Our aim is to evaluate the effectiveness of the BMS in diverting feces from the perianal wide surgical wound in patients with Fournier's gangrene. METHODS: BMS(TM) was applied in five patients (male: 2, median age; 44) with Fournier's gangrene from January 2000 to September 2001. The treatments consist of three times a day wound dressing after wide surgical debridement and intravenous antibiotic therapy. For evacuation of feces, twice daily warm saline irrigation was administered via BMS(TM) or low daily doses of polyethylene glycol solutions were orally taken in. An endoscopic and anorectal manometric study was done to evaluate possible mucosal complications and anorectal functional changes. RESULTS: The average duration of the BMS application was 41 (range, 22~63) days. The result of a manometric study after immediate removal of the BMS(TM) showed a decreased mean resting pressure (range: 22~36 mmHg) and a decreased mean squeezing pressure (range: 32~39 mmHg). After 3 days, the sphincter pressure had improved markedly: mean resting pressures of 38, 45, 60, and 63 mmHg and mean squeezing pressure of 78, 89, 91, and 101 mmHg respectively. Fecal incontience was not noted in any patient. Other possible mucosal complications were not noted. There were no mortalit. CONCLUSIONS: BMS(TM) application in Fournier's gangrene patients after surgery successfully avoids a defunctioning colostomy. Furthermore, no significant complications were noted over a prolonged period up to 63 days.

The Effect of Body Composition and Age on the Metabolic Response to Stress after Colorectal Surgery

PURPOSE: We wanted to evaluate the effect of body composition and age on the metabolic responses before and after elective colorectal resection. METHODS: We studied 20 active, healthy patients who underwent elective colorectal surgery. Their body composition was measured by using a Bioelectrical Impedance Analyzer. The O2 and CO2 consumption (VO2 and VCO2), respiratory quotient (RQ) and resting energy expenditure (REE) were measured by Indirect Calorimetry with using a Ventilated Hood System. RESULTS: The median age was 55 year (range: 35~70 year). The serum glucose, cortisol, insulin, C-reactive protein, cathecholamine and total body water (TBW), postoperative mean VO2, VCO2 and REE were all independent of patient age. The REE increased 9+/-4.3% after operation, but this increase was not related to age. The TBW was strongly related with the preoperative VO2 and VCO2, and the preoperative REE (r2=0.42~0.57, P<0.001). The postoperative VO2, VCO2 and REE were dependent on the TBW. The preoperative REE was dependent on the age, gender, preoperative TBW and body muscle mass (r2=0.526, P<0.000). The postoperative REE was dependent on the TBW and it was strongly related with the preoperative value (r2=0.796, P< 0.000). The postoperative day change of the REE was dependent on the postoperative day change of the TBW (r2=0.700, P=0.04). CONCLUSION: The TBW was not related to age. The TBW was the most valuable index to predict the change of the postoperative REE. Therefore, the preoperative TBW may be considered as the meaningful indicator to predict the change of the postoperative REE.

Investigation of Defecographic Findings in Patients with Pelvic Outlet Obstructive Disease

PURPOSE: Defecography is a dynamic investigation which can influence clinical decision making in patients with pelvic outlet obstructive disease (POOD). The current study was designed to establish defecographic findings in patients with POOD. Specifically, we sought to assess the physiologic characteristics of categorized types by using anorectal physiologic tests. METHODS: One hundred seven patients (disease group; 45 men, 62 women) with POOD were retrospectively categorized as type I [non-relaxation of puborectalis (NRPR) only, n=19], type II [NRPR and rectocele, n=20], type III [NRPR, rectocele, and dynamic perineal descent (PD), n=17], type IV [deformed rectocele, mild-to-moderate fixed PD, and absence of NRPR, n=29], and type V [rectocele, severe fixed PD, and absence of NRPR, n=20] on the bases of defecographic findings. The ability to evacuate, the frequency/degree of intarectal intussusception (IRI), and the size of the rectocele were evaulated in these defecographic types of POOD. Age, duration of symptoms, and the physiologic findings of anal manometry and EMG/PNTML were compared for the five types. Eighteen healthy volunteers who had no defecation difficulty were used to estimate the normal findings of defecography. RESULTS: The age and the sex showed no significant differences among the types. The duration of symptoms was gradually lengthened from type I to V (P<0.01). The ability to evacuate in patients with POOD was significantly worse (failed to effectively evacuate) compared to that in the healthy volunteers (P<0.01). The frequency of IRI was increased more and more from type I to V (P<0.01). The size of the rectocele was significantly increased in types V compared to the other types (P<0.01). Manometric and neurologic findings, including EMG/PNTML, revealed no significant differences among the types. CONCLUSIONS: Even though there were no specific differences in the findings of the anal manometric and neurologic tests, the evacuation dynamics; were different in the five defecographic categories of patients with POOD. Specifically, these differences were relevants to the presence of NRPR, rectoceles, IRI, and perineal descent.

Complete Single Stage Management of Left Colon Cancer Obstruction with a New Devices

Intraoperative antegrade colonic irrigation for single stage procedure in left colon cancer obstruction is a preferred technique recently however, synchronous pathology cannot be detected. A new device that enables easy intraoperative irrigation and colonoscopy before resection of tumor was devised. PURPOSE: To evaluate the efficacy of the new device for single stage procedure in left colon cancer obstruction. METHODS: The new device (NICI; MITech co., Ltd, Seoul, Korea) consists of a Y-shaped teflon tube of maximum diameter 2.9, 3.5 and 4.1 cm, one proximal end is designed to connect with the dilated colon just proximal to the lesion. Two distal branches are for drainage of fecal matter and for retrograde insertion of irrigation catheter and subsequent colonoscope respectively. RESULTS: There were 53 patients (27 male, median age 64, range; 28~82) who underwent this procedure. No extraintestinal leaks were encountered. The volume of saline used was 12 (range; 6 to 27) Liters over 14 (range; 9 to 22) minutes. Subsequent colonoscopic examination added 10 (range, 8 to 15) minutes to the entire operation in 28 patients. There were one anastomotic leakage and 2 wound infections, however, there was no operative mortality. On-table colonoscopy resulted in extended resection in 3 cases because of synchronous malignancy in frozen biopsy and found synchronous polyps in 13 of 28 cases. CONCLUSIONS: The new device enabled safe, simple and time saving single stage surgical management of left colon cancer obstruction. The ability to perform on-table colonoscopy enabled treatment of synchronous bowel pathology.

The Economic Efficiency of the Single Stage Management of Left Colon Cancer Patient

PURPOSE: Two-stage management with Hartmann's procedure is the most common procedure used for the treatment of obstructive left colon cancer with or without perforation. However, single-stage procedures have gained popularity recently with reports that show little difference in safety compared to the conventional multi-stage procedures. To evaluate the economic advantage of single stage procedure compare with two stage procedure in emergent left colonic pathology. METHODS: Eleven patients (SP; single stage procedure) without other accompanying diseases among 15 patients who entered the emergency room and treated by the single stage procedure using the intraoperative irrigation for the left colon obstructions with or without perforation during the period from July of 1999 to November of 2000, were compared in their costs retrospectively with 11 patients (MP; multiple stage procedure) without other accompanying diseases and had final reduction of stoma out of 28 patients treated by Hartman's procedures including the resections of lesions during the period from September 1996 to May 1999 with the same diagnosis. The costs were compared using Mann-Whitney U tests, with data on the costs of overall treatments, operations, anesthesia, admission room, medications, test/evaluations, and managements as well as days of hospital stay, all on the record of accounting department. The relationships of the factors to the total cost of treatment were evaluated using Multi-variant regression analysis, and the pre-operative physiologic status were compared using APACHE III scoring system. The total treatment cost did not include optional treatment costs, uninsured admission room costs, and the costs of colonic irrigator used in the operations for the SP. RESULTS: There were no significant difference in the age and gender of the two groups as 67 +/-15 years with 6 males for the SP and 6+/-19 years with 7 males for the MP. The preoperative physiologic status of patients, in APACHE III scoring system, were 29.1+/-10.6 in the SP and 26.1+/-8.2 in the MP without any significant difference between the two groups. The average of hospital stay showed a significant difference between two groups as 17.1+/-6.2 (range: 13-25) days for the SP and 31.3 (range: 24-43) days for the MP (p<0.01). The average of total costs showed also a significant difference in two groups as 3,938 687 (range: 3,017-4,974) thousand won for the SP and 7,543 1,851 (range: 5,314-9925) thousand won for the MP (p<0.01). It showed that the SP had roughly 50, 53, 76, 79, and 72% reductions of costs over operations, anesthesia, admission room, medications, tests/evaluations, and managements. The analysis of the overall costs of treatments showed 3,540 thousand won reduction in SP. CONCLUSIONS: Single stage procedure using intraoperative colonic irrigation technique showed no difference in safety but has an economical advantage over the conventional multiple stage in the management of emergent left colonic obstruction or perforation patients.

The Safety of Intraoperative Colonic Irrigation for Single Stage Procedure in Emergency Based Left Colonic Pathology

Staged procedures are preferred to single stage procedures in emergency based left colonic obstruction or perforation because of the safety. PURPOSE: To evaluate whether the single stage procedure in emergency based left colonic pathology is not safe. METHODS: We compared medical records of single stage procedure (SP, n=22 male; 10, mean age: 60+/-17, range: 26-82 Yrs) with Hartmanns procedure (HP, n=23 male; 13, mean age: 58+/-16, range: 18-90 Yrs) and diverting loop colostomy (DC, n=19, male; 12, mean age: 59+/-19, range: 19-80 Yrs) in these 4 years. All the patients were admitted via emergency room. Intraoperative colonic irrigation method with newly developed irrigation device (MITech co., Ltd, Seoul, Korea) was used for SP. APACHE III scoring system was applied to evaluate the physiologic status of the patients. Preoperative data were compared with the 1st and 3rd postoperative day (POD). RESULTS: There were no statistically significant differences in patient demographics and preoperative APACHE III scores. The improvement of APACHE III score was significant in SP and DC on the 3rd POD from 29.6+/-20.9 to 22.9+/-10.2 and 25.7+/-13.3 to 21.4+/-14.8 (P<0.05). There was also a significant improvement in DC (25.7+/-13.3 to 21.9+/-12.9, P<0.05) on the 1st POD, however, there was only a tendency of improvement in SP (29.6+/-20.9 to 26.1+/-12.3) without statistical significance. The scores in HP showed no improvement on the 1st and 3rd POD. There were 3 operative mortalities in HP and one in DC. CONCLUSIONS: Our results suggest that the safety of the single stage procedure with newly developed colonic irrigation device is comparable to palliative decompressive loop colostomy and better than Hartmanns procedure in emergency based left colonic pathology.