RESUMEN
PURPOSE: An increasing number of patients are treated with anticoagulation for many medical conditions. Our practice is to suspend warfarin 5-7 days, aspirin 3 days, and clopidogrel (Plavix) 7 days prior to colonoscopy that may require polypectomy. Generally, we accept an INR of ≤1.5 as safe. However, there are no published case series documenting when it is safe to resume these medications after polypectomy. Therefore, the management of anticoagulation after polypectomy varies. We sought to evaluate the safety of our practice with regard to anticoagulation and polypectomy. METHODS: We conducted a retrospective review of all patients over the age of 18 who underwent colonoscopy with polypectomy while on anticoagulation for various medical comorbidities at our institution over a 15-month period (July 2007 to September 2008). All morbidity and mortality that occurred for the first 3 weeks post-polypectomy was recorded. The Mann-Whitney test was performed using SPSS 15.5. RESULTS: From July 2007 to September 2008, we performed 579 colonoscopies with polypectomy on patients who were on anticoagulation therapy during the study period. Seven (1.2%) patients presented to the Emergency Room or were hospitalized within 3 weeks after polypectomy for lower gastrointestinal bleeding. Distribution of anticoagulants was listed: 2 (28.6%) patients on warfarin, 4 (57.1%) on aspirin, and 1 (14.3%) on clopidogrel. Warfarin was held for, on average, 4 days pre-polypectomy and 1 day post-polypectomy. Aspirin was held, on average, 3 days both pre- and post-polypectomy. Clopidogrel was held, on average 6.5 days pre-polypectomy but restarted immediately post-polypectomy. No statistically significant difference was found between the number of days that anticoagulation was held pre- or post-polypectomy in individuals who did and did not bleed. CONCLUSION: We found that our practice of resuming anticoagulation or antiplatelet agents (warfarin, aspirin, and clopidogrel) post-polypectomy was safe and did not prove to significantly affect the post-polypectomy rate of hemorrhage.
Asunto(s)
Anticoagulantes/administración & dosificación , Aspirina/administración & dosificación , Pólipos del Colon/cirugía , Colonoscopía , Inhibidores de Agregación Plaquetaria/administración & dosificación , Ticlopidina/análogos & derivados , Warfarina/administración & dosificación , Anticoagulantes/efectos adversos , Aspirina/efectos adversos , Clopidogrel , Colonoscopía/métodos , Femenino , Hemorragia Gastrointestinal/inducido químicamente , Humanos , Inhibidores de Agregación Plaquetaria/efectos adversos , Periodo Posoperatorio , Estudios Retrospectivos , Ticlopidina/administración & dosificación , Ticlopidina/efectos adversos , Warfarina/efectos adversosRESUMEN
BACKGROUND: Despite early studies reporting significant decreases in postoperative pain and morbidity with the procedure for prolapse and hemorrhoids (PPH) compared to traditional hemorrhoidectomy, certain complications and long-term efficacy remain uncertain. This study was performed to assess the prevalence of usage of PPH and the observed postoperative complaints and complications. METHODS: A questionnaire was mailed to national and international members of the American Society of Colon and Rectal Surgeons (ASCRS) and the accumulated data were reviewed. RESULTS: The rate of response to the 2,642 questionnaires was 28.5% (n=754). Of the 754 respondents, 531 (70.4%) had performed PPH and 451 (84.9%) continued to perform PPH. The most commonly reported postoperative complaint was delayed postoperative pain. Pain lasting for months was reported by 15.1% of respondents. Persistent bleeding was reported by 34.5%, and 40.9% felt there is a post-PPH syndrome. CONCLUSIONS: Some long-term studies critically examining PPH have come to fruition. A majority of respondents continued to perform PPH. Nearly half of these agreed that there is a "post-PPH syndrome" relating to postoperative morbidities. The most disturbing morbidity was lasting perineal pain of unexplained etiology demanding challenging management. Persistent bleeding from hemorrhoidal disease distal to the staple line requires further management and raises the question as to the use of PPH as a permanent remedial procedure.
Asunto(s)
Hemorroides/cirugía , Complicaciones Posoperatorias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Prolapso Rectal/cirugía , Grapado Quirúrgico/estadística & datos numéricos , Competencia Clínica , Hemorroides/epidemiología , Hemorroides/patología , Humanos , Prevalencia , Prolapso Rectal/epidemiología , Prolapso Rectal/patología , Encuestas y Cuestionarios , Síndrome , Resultado del Tratamiento , Estados UnidosAsunto(s)
Cirugía Colorrectal/métodos , Endoscopía/métodos , Hemorroides/diagnóstico , Hemorroides/cirugía , Cirugía Colorrectal/efectos adversos , Endoscopía/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Manometría/métodos , Dolor Postoperatorio/fisiopatología , Probabilidad , Proctoscopía/métodos , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Grapado Quirúrgico , Resultado del TratamientoRESUMEN
Recent studies have suggested that virtual colonoscopy (VC) and actual colonoscopy (AC) have similar efficacy for detection of polyps >6 mm. However, procedural risks with emerging technology such as VC need to be assessed before widespread implementation. We propose to demonstrate complication rates after AC that can be used for a comparative benchmark in VC. From 1994 to 1999 all patients undergoing AC who sustained perforation that required operation were analyzed for the mortality and complications. There were 26,162 consecutive colonoscopies that required 21 operations for perforation. Of these 16,948 (65%) colonoscopies were diagnostic and 9,214 (35%) were therapeutic with 11 (0.06%) and 10 (0.11%) operations respectively. Overall risk for colonoscopic perforation that requires operation was one in 1,246 (one in 1,541 for diagnostic and one in 921 for therapeutic). Five perforations were oversewn, 15 were resected (five with stoma), and one was drained. One patient died. There were two reoperations. Mortality was 0.006 per cent (one in 16,948) for diagnostic and zero for therapeutic colonoscopy. Overall risk for perforation that requires operation or mortality after AC is low. Virtual colonoscopists who propose screening and subsequent therapeutic interventions need to report high volume without complications as the perforation rate requiring operation was one in 1,246.
Asunto(s)
Colon/lesiones , Colonoscopía/efectos adversos , Perforación Intestinal/etiología , Pólipos del Colon/diagnóstico , Colonoscopía/métodos , Humanos , Perforación Intestinal/terapia , Factores de Riesgo , Interfaz Usuario-ComputadorRESUMEN
INTRODUCTION: Readmission after discharge from the hospital is an undesirable outcome. In an attempt to prevent unplanned readmissions after abdominal or perineal colon resection, we proposed to identify risk factors associated with return to the hospital. METHODS: Study participants consisted of 249 patients who were operated on from July 1, 1996, to March 30, 1998. All patients who were readmitted within 90 days of discharge from the hospital after surgery were evaluated for the study. A retrospective review of charts was performed to assess whether readmission within 90 days was a direct consequence of the recent operation (unplanned related readmission). These patients were compared with a control group consisting of patients who were never readmitted or who were readmitted with an unrelated problem. RESULTS: Of the 249 patients, 59 (24 percent) were readmitted within 90 days of discharge from the hospital. Twenty-two (9 percent) were unplanned related readmissions. Ten patients were readmitted with unrelated emergencies, and 27 patients were readmitted electively. In the unplanned related group, there was no correlation between age, gender, admission diagnosis, activity status, or postoperative length of stay and the likelihood of readmission. Patients with multiple chronic medical problems or those who developed postoperative complications did not have a higher readmission rate. Patients with ulcerative colitis or those who underwent abdominoperineal resection or total/subtotal colectomy had a higher incidence of readmissions, although the difference was not significant. The mean interval between discharge from the hospital and readmission with a related complication was 19 days. Small-bowel obstruction was the most common reason for readmission, and all cases resolved with conservative management. Mean length of stay during all readmissions was 8 days. CONCLUSION: The incidence of unplanned related readmissions 90 days after abdominal or perineal colon resection is 9 percent, and these readmissions could not be predicted from the postoperative course. Because 82 percent of unplanned readmissions occurred within 30 days, this time frame is suitable for computerized comparative analysis.
Asunto(s)
Enfermedades del Colon/cirugía , Readmisión del Paciente/estadística & datos numéricos , Enfermedades del Recto/cirugía , Adulto , Anciano , Colectomía/efectos adversos , Femenino , Predicción , Humanos , Ileostomía/efectos adversos , Incidencia , Masculino , Persona de Mediana Edad , Alta del Paciente , Complicaciones Posoperatorias , Pronóstico , Estudios Retrospectivos , Factores de RiesgoRESUMEN
There is a lack of consensus regarding the optimal operative treatment for full-thickness rectal prolapse. We describe our experience in the management of procidentia and evaluate our current practice for improvement of results. The medical records of patients undergoing surgery for rectal prolapse between 1989 to 1999 were retrospectively reviewed. A total of 36 perineal proctosigmoidectomies (PPSs) and 29 abdominal procedures [17 anterior resections (ARs) and 12 Ripstein procedures (RPs)] were performed during the 10-year period. Patients undergoing PPS were significantly older and had more comorbidities. Mean operating time and length of hospital stay were shorter for the PPS group. Early and late postoperative complication rates were also significantly lower in the PPS group. Six patients (16%) in the PPS group developed recurrence at a mean follow-up of 50 months. Operation under general anesthesia or removal of a longer segment of prolapsed bowel did not reduce recurrence after PPS. No full-thickness recurrence was noted after AR or RP. We conclude that abdominal procedures (AR and RP) have the lowest recurrence but at a significantly higher cost in terms of complications. PPS is a valuable option in selected patients and can be performed with minimal morbidity and a relatively low recurrence rate.
Asunto(s)
Complicaciones Posoperatorias , Prolapso Rectal/cirugía , Músculos Abdominales/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Colon Sigmoide/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Perineo/cirugía , Recto/cirugía , Recurrencia , Estudios RetrospectivosRESUMEN
The vast majority of hyperplastic polyps are small, left-sided, and inconsequential in nature. However, hyperplastic polyps that are large, right-sided, mixed, and found in association with a family history of carcinoma may represent an "atypical" group, and their clinical significance is uncertain. We believe that these atypical lesions should not be lumped together with the common variety of diminutive hyperplastic polyps. Rather, when such hyperplastic polyps are encountered, they should be excised and the patient should be placed on regular colonoscopic surveillance.
Asunto(s)
Enfermedades del Colon/patología , Transformación Celular Neoplásica , Pólipos del Colon/patología , Femenino , Humanos , Hiperplasia , MasculinoRESUMEN
Dieulafoy's lesion is an unusual source of massive lower gastrointestinal hemorrhage. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. Although Dieulafoy's lesions were initially described only in the stomach and upper small intestine, they are being identified with increasing frequency in the colon and rectum. To our knowledge, however, Dieulafoy's lesion of the anal canal has not been described previously. We present two patients with Dieulafoy's lesion of the anal canal who presented with sudden onset of massive hemorrhage. The clinicopathologic features of this unusual clinical entity are discussed and suggestions are made for diagnosis and management.
Asunto(s)
Angiodisplasia/diagnóstico , Hemorragia Gastrointestinal/etiología , Mucosa Intestinal/irrigación sanguínea , Enfermedades del Recto/diagnóstico , Recto/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Angiodisplasia/cirugía , Arteriolas/cirugía , Femenino , Hemorragia Gastrointestinal/cirugía , Hemorroides/diagnóstico , Hemorroides/cirugía , Humanos , Enfermedades del Recto/cirugía , Recurrencia , Técnicas de SuturaRESUMEN
The aim of this study was to review experience with transanal endoscopic microsurgery (TEM) and to assess its applicability to an existing practice of colorectal surgeons. Patients undergoing TEM excision of rectal lesions from March 1997 through May 1999 were selected for this study. Medical records were reviewed retrospectively to obtain pertinent data, including indications for TEM, tumor size, distance from anal verge, duration of operation, completeness of tumor resection, postoperative complications, duration of stay and follow-up, and recurrence. Thirty-one patients underwent TEM during the 2-year period. Indications for TEM included benign disease in eight patients and cancer in 23 patients. Mean distance of the tumor from the anal verge was 8.3 cm. Mean size of the lesion was 2.8 cm, and mean specimen size was 4.5 cm. Larger specimen sizes allowed for tumors to be removed with negative margins (97%) in all cases but one. Mean duration of operation was 140 minutes (including set-up time), and mean duration of hospital stay was 1.2 days. Major postoperative complications occurred in one patient. Mean duration of follow-up was 15 months, and recurrence developed in two patients during this period. Transanal endoscopic microsurgery excision of rectal lesions with negative margins was possible in 97% of cases with minimal morbidity and a short-duration hospital stay. Follow-up was too brief to evaluate recurrence, but the thoroughness of resection of tumor in a high proportion of cases is promising.
Asunto(s)
Microcirugia/métodos , Proctoscopía/métodos , Enfermedades del Recto/cirugía , Neoplasias del Recto/cirugía , Anciano , Colonoscopía , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Microcirugia/efectos adversos , Microcirugia/instrumentación , Recurrencia Local de Neoplasia/etiología , Estadificación de Neoplasias , Proctoscopía/efectos adversos , Enfermedades del Recto/diagnóstico , Neoplasias del Recto/clasificación , Neoplasias del Recto/diagnóstico , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Retención Urinaria/etiologíaRESUMEN
PURPOSE: The occurrence of neoplasia after ureterosigmoidostomy is well-documented in the literature. Because of its rarity, few general surgeons will gain significant exposure to this entity, and colorectal surgeons are likely to be involved with the care of these patients. The purpose of this article is to apprise colorectal surgeons about the management of neoplasia after ureterosigmoidostomy and to familiarize them with the unique anatomy of the reconstructed pelvis. METHODS: We performed a MEDLINE search to identify articles on ureterosigmoid tumors. The theories regarding the cause and pathology of these tumors were critically analyzed. A consensus was developed for screening patients with ureterosigmoidostomy and for treatment of neoplasia. RESULTS: The incidence of carcinoma after ureterosigmoidostomy ranges from 2 to 15 percent. Polyps are more common, and it seems that these tumors also follow the sequence of adenocarcinoma that is seen in the common variety of colorectal neoplasia. Neoplastic changes begin with the interaction of urine and feces and the healing colonic mucosa. Both production of nitrosamines by the action of bacteria on urine and DNA damage caused by reactive oxygen radicals produced by neutrophils at the healing anastomosis have been implicated in the pathogenesis of neoplasia. The latent period between formation of ureterosigmoidostomy and the appearance of carcinoma is between 20 and 26 years. Obstructive urinary symptoms that develop more than two years after ureterosigmoidostomy should be viewed with suspicion. The patient should be investigated with a CT scan and colonoscopy, and a barium enema may be required to delineate the anatomy further. If a benign tumor is encountered during colonoscopy, it may be removed by snare polypectomy. For a malignant tumor the segment of colon with ureteric implants should be excised, along with its lymphatic drainage. Bowel continuity is restored primarily, and the ureters are implanted in an ileal conduit. CONCLUSIONS: Patients with ureterosigmoidostomy should be followed closely for the rest of their lives. The aim of screening is to identify and treat neoplasia before malignancy develops. Furthermore, early detection of neoplasia by close screening will improve survival. Although urine cytology and occult blood are inexpensive tests, colonoscopy remains the criterion standard for follow-up of these patients. Annual colonoscopic surveillance should be started soon after the ureterosigmoidostomy but not later than five to six years after the procedure. Patients who are noncompliant with the vigorous follow-up schedule should be offered the option of resection of the colonic segment at risk with urinary diversion.
Asunto(s)
Anastomosis Quirúrgica/efectos adversos , Colon Sigmoide/cirugía , Neoplasias del Colon/etiología , Uréter/cirugía , Derivación Urinaria/efectos adversos , Adenocarcinoma/diagnóstico , Adenocarcinoma/etiología , Adenocarcinoma/cirugía , Carcinoma/diagnóstico , Carcinoma/etiología , Carcinoma/cirugía , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/cirugía , Pólipos del Colon/diagnóstico , Pólipos del Colon/etiología , Pólipos del Colon/cirugía , Colonoscopía , Daño del ADN , Heces , Estudios de Seguimiento , Radicales Libres/metabolismo , Humanos , Incidencia , Mucosa Intestinal/fisiopatología , Mucosa Intestinal/cirugía , Tamizaje Masivo , Neutrófilos/metabolismo , Nitrosaminas/metabolismo , Especies Reactivas de Oxígeno/metabolismo , Factores de Tiempo , Orina , Cicatrización de HeridasRESUMEN
PURPOSE: Colonoscopy is the preferred method for colorectal cancer surveillance of high-risk patients. Despite its high sensitivity, polyps or cancers may be undetected by colonoscopy and later attributed to an accelerated adenoma-carcinoma sequence. This study assesses how the characteristics of colorectal cancers found at intervals between surveillance relate to the adenoma-carcinoma sequence and its prevention. METHODS: The records of 557 patients with colorectal cancer that were diagnosed from January 1, 1990, to December 31, 1996, were reviewed to identify those patients who had prior colonoscopic surveillance within 60 months of their diagnosis. RESULTS: There were 29 (5.2 percent) patients who had one or more colonoscopies before diagnosis of their colorectal cancer. Mean interval between diagnosis and prior colonoscopy was 23 (range, 4-59) months. The distribution of cancers included nine cecum, two ascending, three hepatic flexure, five transverse, one splenic flexure, three descending, two sigmoid, three rectum, and one anal canal. The mean tumor size was 4.4 cm for the cecum and 2.4 cm for all other locations. There were 7 Tis, 6 T1, 4 T2, and 12 T3 lesions. Six patients with T3 lesions had prior colonoscopies within 24 months of the diagnosis. Three of four patients with lymphatic metastases had tumors in the cecum. Twenty tumors (69 percent) were well or moderately differentiated. Mean follow-up was 41 (range, 7-95) months with two local recurrences and two unrelated deaths. CONCLUSIONS: Size, differentiation, and stage of colorectal cancer in addition to the interval to diagnosis suggest that the majority of cancers found during surveillance colonoscopy followed prior false-negative examinations. Because cecal landmarks are most constant, prior photographic documentation may help to prove or disprove fast growth of cancers found in the cecum during surveillance colonoscopy.
Asunto(s)
Colonoscopía , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/patología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Estudios RetrospectivosRESUMEN
Retrorectal masses comprise a varied group of rarely encountered tumors. We present the case of a 42-year-old white woman with a retrorectal carcinoid tumor treated by abdominosacral resection. Diagnostic and therapeutic strategies are discussed.
Asunto(s)
Tumor Carcinoide/cirugía , Neoplasias Retroperitoneales/cirugía , Adulto , Tumor Carcinoide/diagnóstico , Femenino , Humanos , Imagen por Resonancia Magnética , Neoplasias Retroperitoneales/diagnóstico , Sacro/diagnóstico por imagen , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
PURPOSE: This study is designed to review a carcinoembryonic antigen (CEA)-driven postoperative protocol designed to identify patients suitable for curative reresection when recurrent colorectal cancer is identified. METHODS: A total of 285 patients who were operated on for colon or rectal carcinoma between 1981 and 1985 were evaluated (with CEA levels) every two months for the first two years, every three months for the third year, every six months for years 4 and 5, and annually thereafter. CEA levels above 5 microg were considered abnormal and were evaluated with diagnostic imaging and/or endoscopy. RESULTS: Follow-up was available for 280 patients (98.2 percent). Distribution of patients by Astler-Coller was: A, 14 percent; B1, 20 percent; B2, 39 percent; C1, 5 percent; C2, 21 percent. There were 62 of 280 patients (22 percent) who developed elevated CEA levels, with 44 patients who demonstrated clinical or radiographic evidence of recurrence. Eleven patients were selected for surgery with curative intent (4 hepatic resections, 1 pulmonary wedge resection, 2 abdominoperineal resections, 2 segmental bowel resections, and 2 cranial metastasectomies). Three of 11 patients (27 percent) benefited and have disease-free survivals greater than 60 months. Of the 223 patients without elevated CEA, 22 (9.9 percent) had recurrent cancer without any survivors. Overall, 3 of 285 patients (1.1 percent) were cured as a result of CEA follow-up. CONCLUSION: CEA-driven surgery is useful in selected patients and can produce long-term survivors.
Asunto(s)
Biomarcadores de Tumor/sangre , Antígeno Carcinoembrionario/sangre , Neoplasias Colorrectales/cirugía , Recurrencia Local de Neoplasia/diagnóstico , Anciano , Neoplasias Colorrectales/sangre , Neoplasias Colorrectales/mortalidad , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Recurrencia Local de Neoplasia/sangre , Cuidados Posoperatorios , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Factores de TiempoRESUMEN
BACKGROUND: Transanal repair of rectocele involving the suprasphincteric portion of the rectovaginal septum has been shown to provide excellent results in up to 90 per cent of cases. Selection of patients suitable for repair is important. Rectocele with concomitant cystocele is best repaired transvaginally. An alternative approach is recommended for enterocele. METHODS: With the patient in the prone position and using local anaesthesia, a mucomuscular endorectal flap is raised and the underlying tissues are plicated. The excessive flap is excised, and the cut edges are approximated. A retrospective review of 123 consecutive cases of transanal repair of rectocele was conducted. Patient satisfaction and complications were compared with those in a previously reported study. RESULTS: Overall patient satisfaction improved from 63 per cent of 59 patients in an earlier study to 82 per cent in this report. The overall complication rate decreased from 7 to 3 per cent. CONCLUSION: This study demonstrates the validity of a simple technique of transanal repair of rectocele in an ambulatory setting. Minimal morbidity and successful outcome can be achieved with this procedure.