RESUMEN

An ongoing debate exists regarding the feasibility of placing self-expanding metallic stents (SEMS) within 5 cm of the anal verge. Traditionally, SEMS have been considered contraindicated for patients with a malignant rectal obstruction within this region due to potential impact on the anorectal ring or anal canal, which can cause incontinence, proctalgia, and tenesmus. However, in the case of a 63-year-old female who presented with distention, abdominal pain, and diminishing stool output, the rectal exam identified a bulky fixed mass. Imaging studies revealed large bowel obstruction and high-grade stricture, with a minuscule residual lumen. Endoscopy identified a bulky mass obscuring the lumen at 5 cm from the anal verge, and biopsy confirmed adenocarcinoma. Despite the traditionally held contraindication, a 2.5 cm × 9.0 cm colonic stent was successfully deployed, leading to brisk colonic decompression. This allowed the patient to promptly undergo chemoradiotherapy.

RESUMEN

BACKGROUND: We evaluated the effect of neoadjuvant therapy (NAT) on lymph node harvest in rectal cancer patients undergoing anatomic resection with curative intent. METHODS: A prospectively maintained database was retrospectively queried for rectal cancer cases from 1990 to 2010. Demographic data, NAT, and lymph node yield were analyzed. Nonanatomic resections were excluded. RESULTS: Five hundred two cases were identified; the mean age was 68 years (range 34-89), and 56% were men. One hundred fifty-one (30%) patients received NAT. Overall, the lymph node yield was diminished in proctectomy specimens after NAT (mean = 9, median = 7) compared with specimens without therapy (mean = 13, median = 10, P = .001). Age was not a significant factor in the lymph node yield (P = .213 and .329). Among patients treated with NAT, younger patients had a significantly lower lymph node yield (P < .0001). CONCLUSIONS: A decreased lymph node yield in proctectomy specimens from patients treated with NAT is consistent with prior studies. Younger patients had a greater reduction in lymph node harvest after NAT compared with senior patients.

Asunto(s)

RESUMEN

PURPOSE: The purpose of this study was to evaluate cryptoglandular fistula surgery outcomes in men with common types of fistulae. METHOD: A database review identified study patients. Exclusion criteria included history of previous fistula, previous anorectal surgery, inflammatory bowel disease, pelvic radiation, complex fistula, age <21 years, and absence of follow-up. RESULTS: Four hundred twenty-five patients met criteria for review. Mean follow-up was 5.8 years. Concurrent abscess at presentation was strongly associated with poorer outcomes. New-onset seepage is more common with seton treatment (P = 0.01), but seepage resolution occurred less commonly with fistulotomy (P <0.01). CONCLUSIONS: Although both treatments are highly successful, men treated with primary fistulotomy are more likely to heal than seton patients. Fistulotomy patients have less early postoperative seepage than seton patients, but when this is present it is less likely to resolve. Presentation with concurrent abscess is strongly associated with poorer outcomes.

Asunto(s)

RESUMEN

BACKGROUND: The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse. METHODS: Consecutive patients were identified from a surgical database and evaluated by chart review. RESULTS: Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications. CONCLUSIONS: Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.

Asunto(s)

RESUMEN

PURPOSE: Initial success rates for fibrin glue ablation of cryptoglandular transsphincteric fistulas have been disappointing. We examined long-term outcomes after initially successful fibrin glue ablation of cryptoglandular transsphincteric fistulas. METHODS: Retrospective review identified 36 adult patients with cryptoglandular transsphincteric fistula Tisseel VH(R) fibrin glue ablation that was performed from May 2000 to March 2005. Fibrin glue ablations were performed under supervision of fellowship-trained colorectal surgeons. Follow-up interval was based on time until recurrence of fistula or time of last fistula-free evaluation. RESULTS: Twenty-four men and 12 women patients had a mean age of 50 (range, 27-85) years. Twenty patients responded to initial fibrin glue ablation treatment. Two additional patients healed with secondary fibrin glue ablation. Sixty-six percent (22/33 patients) of cryptoglandular transsphincteric fistulas were closed at three months. Eleven patients failed fibrin glue ablation at a mean of 33 (range, 6-41) days. Seventeen of 22 short-term success patients (3 months) were available for long-term follow-up. Ninety-four percent (16/17 patients) remained healed at final long-term follow-up. The remaining patient recurred just before the six-month follow-up. CONCLUSIONS: Despite the suboptimal early success rate of fibrin glue ablation for cryptoglandular transsphincteric fistulas, when a fistula does close for at least six months this appears to be a durable closure. A single patient recurred after appearing healed at the three-month check.

Asunto(s)

RESUMEN

PURPOSE: Previous studies identified reduction in pain and complications with stapled hemorrhoidopexy relative to conventional hemorrhoidectomy. Previously, the presence of resected squamous epithelium and a staple line height <20 mm above the dentate line were predictive of postoperative pain. The purpose of this study was to further investigate and refine the role of staple height in the prediction of postoperative outcomes. METHODS: From July 2002 to October 2004, 75 patients with symptomatic Grade 3 and 4 mixed hemorrhoids underwent stapled hemorrhoidopexy in two teaching institutions with prospective data collection. All procedures were performed under the direct supervision of two colorectal teaching staff. The majority were performed under monitored anesthesia care as outpatient procedures. Preoperative, intraoperative, and postoperative patient characteristics were evaluated. This included demographics, staple line height, specimen histology, complications, days to return to work, duration of narcotic pain medicine, and preoperative/postoperative tone and seepage. The results were subjected to statistical analysis using t-test and ANOVA. RESULTS: Seventy-five patients with a median age of 49 (range, 25-87) years were identified. Histology identified 62 specimens with columnar and/or transitional cells, 10 with squamous epithelium, and 3 with muscle present. Overall complication rate was 14 percent. Complications included three readmissions for pain control, three acute postoperative anal fissures, two postoperative bleeds (with one requiring examination under anesthesia without intervention), one patient with subcutaneous emphysema, and one admission for fecal impaction. Staple line height was not a statistically significant predictor of postoperative complication. Median return to work was 14 (range, 1-31) days. Median duration of narcotic use was six (range, 0-40) days. Patients with a staple line height>22 mm required a significantly shorter duration of narcotic pain management (P=0.024). Median follow-up was 24 (range, 9-253) days. Staple line heights below 20 mm had a mean return to work of 15 days. A staple line height>20 mm had a mean return to work of nine days. Staple line height was inversely related to return to work (P=0.01). CONCLUSIONS: A hemorrhoidopexy staple line>or=22 mm above the dentate line correlates with a significantly shorter need for postoperative narcotics (P=0.024) and an earlier return to work (P=0.017). Staple line distance above the dentate line meaningfully impacts comfort-based outcomes.

Asunto(s)

RESUMEN

BACKGROUND: Debate exists regarding whether the use of topical agents and Botox injections are as efficacious as sphincterotomy for the treatment of chronic anal fissure. METHODS: A retrospective review was performed to assess changes in management and outcomes of chronic anal fissure care in a community based colorectal practice between the individual years 1994 and 2003. RESULTS: Forty-seven patients in 1994 underwent lateral partial internal sphincterotomy and had a 100% healing rate. Thirty-nine patients were treated in 2003, with 32 undergoing Botox injection and 7 undergoing sphincterotomy initially. Of the Botox patients, 35% had recurrence, and 7 subsequently required sphincterotomy. Ultimate healing rates in 2003 were 97%. Time to heal was markedly prolonged in 2003 compared with 1994. Complication rates were similar, and there was no lifestyle-altering incontinence. CONCLUSIONS: Our review documents a significant change in the community approach to chronic fissure management. The addition of multiple treatment modalities prolongs time to healing from initial evaluation, but they allowed 72% of patients to avoid the need for permanent sphincter division while maintaining ultimate rates of healing.

Asunto(s)

RESUMEN

PURPOSE: Colonoscopy is believed to be inadequate in 4 to 24 percent of procedures. Barium enema often is utilized to complete the examination. In radiology literature, a successful barium enema in this setting requires only that the cecum has been reached. In this study, completion barium enema was assessed for both completeness and quality of proximal visualization. METHODS: The charts of 16,216 patients undergoing colonoscopy at Saint Vincent Health Center from July 1995 to July 2003 were reviewed to identify patients who underwent barium enema within six months of an incomplete colonoscopy. Incomplete colonoscopies were audited for history of previous abdominal/pelvic surgery, level of colon attained, and apparent reasons for failure. Corresponding barium enema reports were evaluated in a similar fashion. RESULTS: In 485 patients (2.9 percent), colonoscopy was incomplete. One hundred eighteen patients underwent barium enema after incomplete colonoscopy. In these patients, sharp angulation (42 percent) or redundancy/looping (31 percent) most often limited endoscopy. Among the barium enema studies, 91 (77 percent) were technically adequate. Twenty-seven studies were suboptimal (poor preparation/intolerance = 7, redundancy = 6, poor filling = 6, stricture/narrowing = 6, severe diverticulosis = 2). Two patients demonstrated additional polyps. There was no correlation between reasons for endoscopic failure and inadequacy of barium enema. Completeness of barium enema was not affected by previous pelvic surgery. Immediate barium enema was no less complete than a delayed study. CONCLUSIONS: The reliability of barium enema after incomplete colonoscopy is less than previously reported.

Asunto(s)

RESUMEN

PURPOSE: Historically, there has been reluctance to use nonabsorbable synthetic mesh for repair of abdominal-wall defects in an operative field in which the presence of open bowel is accompanied by the potential for contamination. Some believe the risk of wound infection and mesh removal in this setting to be unacceptably high. The purpose of this study was to evaluate the safety and efficacy of nonabsorbable mesh used for hernia repair in the presence of a stoma or at the time of colon resection. METHODS: All patients undergoing elective surgical implantation of mesh with concomitant open bowel from 1987 to 2001 were retrospectively reviewed. Computer database identified all patients undergoing parastomal hernia repair, ventral hernia repair with a stoma present, hernia repair with concomitant bowel resection, and colostomy closure with repair of hernia. No patients so identified were excluded. Follow-up was attained on all patients by chart review and telephone survey. The data was statistically analyzed by chi-squared test using a P value of <0.05 for statistical significance. RESULTS: Twenty-nine patients were identified as having undergone 30 elective hernia repairs using nonabsorbable mesh. The repairs were performed in the presence of a stoma or in conjunction with bowel resection. All patients received bowel preparation. Included were 11 patients undergoing parastomal hernia repair (37 percent), 14 patients undergoing ventral hernia repair in the setting of open bowel (47 percent), and 5 patients in whom mesh repair of ventral and parastomal hernias were performed simultaneously (16 percent). Hernias recurred in 13 patients (43 percent). Overall recurrence for mesh repair at a parastomal site was 63 percent; overall recurrence at an incisional hernia site was 21 percent. The risk of wound complications after mesh placement in the setting of open bowel was assessed. Wound seromas developed after surgery in four patients (13 percent). Seromas were all treated successfully by aspiration. Wound infections occurred after surgery in two patients (7 percent). Wound infection occurred exclusively in sites of parastomal repair representing 2 of 16 (13 percent) of parastomal hernia sites. Infection with fistula necessitated mesh removal in one of these two cases. No chronic sinuses were observed. Incidences of recurrence and wound infection were statistically independent of type of hernia, variety of mesh, or operative approach. CONCLUSION: After bowel preparation, nonabsorbable mesh can be used for elective repair of incisional hernia in the presence of open bowel with an expectation of minor morbidity, minimal risk of infection, and an acceptable rate of recurrence. Nonabsorbable mesh can be used for elective repair of parastomal hernia in a similar setting with a low risk of infection independent of surgical approach. Although safe, local mesh repair of parastomal hernia was, in this study, accompanied by a high rate of recurrence.

Asunto(s)