Augustine Iroatulam

Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus.

PURPOSE: The aim of this study was to compare the length of postoperative ileus in patients undergoing colectomy by either laparotomy or laparoscopy. METHODS: A total of 166 patients were studied. These patients were divided into two groups: Group 1, in which colectomy was done laparoscopically, and Group 2, consisting of patients undergoing laparotomy. Both groups contained 83 patients who were matched for disease severity, indications for surgery, and procedure. Indications for surgery included sigmoid diverticulitis in 12 (14 percent) patients, polyps in 22 (27 percent), Crohns disease in 21 (25 percent), colorectal cancer in 11 (13 percent), stoma reversal in 8 (10 percent), rectal prolapse in 3 (4 percent), and other indications in 6 (7 percent) in each group. Operations were colectomy with anastomosis (42 ileocolic, 26 colorectal, 6 colocolic, 4 ileorectal, and 2 ileal J pouch) or without anastomosis (3 abdominoperineal resections) performed by the same surgeons during the same time period (January 1993 to October 1996). The nasogastric tube was removed from all patients immediately after surgery in both groups. All patients received a clear liquid diet on the first postoperative day, followed by a regular diet as tolerated. The nasogastric tube was reinserted if two or more episodes of emesis of more than 200 ml occurred in the absence of bowel movement. Patients were discharged from the hospital when tolerating a regular diet without evidence of ileus. Statistical analysis was performed using unpairedt-test and Fishers exact probability test. RESULTS: The male-to-female ratio was 38 to 45 in both groups. A total of 10 (12 percent) and 23 (28 percent) patients in Group 1 and Group 2 had emesis (P=0.02), and the rate of nasogastric tube reinsertion was 5 (6 percent) and 13 (16 percent), respectively (P>0.05). There were significant differences between Groups 1 and 2 relative to the lengths of ileus (3.5±1.3vs. 5.4±1.7 days, respectively;P<0.001), hospitalization (6.6±3.3vs. 8.1±2.5 days, respectively;P<0.002), and operative time (170±60vs. 114±46 minutes, respectively;P<0.001). The morbidity rate was 16 (19.2 percent) and 18 (21.6 percent) in the laparoscopy and laparotomy groups, respectively. CONCLUSIONS: Although early oral intake is safe and can be tolerated by 84 percent of patients after colectomy by laparotomy, laparoscopic colectomy reduced the lengths of both postoperative ileus and hospitalization.

Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy

AbstractBackground: The aim of this study was to evaluate disability after laparoscopic colectomy in patients with benign colorectal disease. Methods: Patients who underwent laparoscopic colectomy for benign colorectal diseases were matched with patients who underwent laparotomy for the same diseases by the same surgeons during the same time period. A standardized questionnaire used to assess disability included days until return to partial activity, full activity, and work. Results: Seventy-one patients who underwent laparotomy were compared with 71 patients who underwent laparoscopy. Pathology included 26 patients with adenoma, 23 with Crohns disease, 13 with diverticulitis, and 9 with reversal of Hartmanns procedure in each group. Procedures were partial colectomy with ileocolostomy, colocolostomy, or colorectostomy. There were no significant differences (p > 0.05) in age (55.8 vs. 59.7 years) or in the incidence of perioperative complications (25% vs. 29%) between the laparoscopy and laparotomy groups, respectively. The operative time was longer in the laparoscopic group than in the laparotomy group: 165 versus 122 min (p < 0.001). However, length of hospitalization, return to partial and full activity, and time off of work were significantly shorter in the laparoscopy than in the laparotomy group: 6.3 versus 9.0 days, 2.1 versus 4.4 weeks, 4.2 versus 10.5 weeks and 3.8 versus 7.5 weeks, respectively (p < 0.01 for all). Conclusions: Laparoscopic colectomy for benign colorectal diseases was associated with significantly less disability than was laparotomy in terms of length of hospitalization as well as return to baseline partial and full activity and employment.

Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction

PURPOSE: The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS: From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent). RESULTS: Whereas 65 patients failed to complete the course of biofeedback therapy, 108( 62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5( 8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P=not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION: Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

Associations of defecography and physiologic findings in male patients with rectocele

This study evaluated the incidence and physiological findings in male patients with rectoceles. All defecographic studies were evaluated by a single colorectal surgeon. After diagnosis of rectocele in male patients, the patients history, symptoms, and physiologic tests (anal manometry, pudendal nerve terminal motor latency [PNTML], assessment and electromyography [EMG]) were studied. A prominent rectocele was defined as one that did not empty during defecography and was associated with outlet obstructive syndrome. Forty (17%) rectoceles were diagnosed in 234 male patients with evacuatory disorders who underwent defecography. Rectoceles were anterior in 19 (48%) and posterior in 21 (52%) patients. The main complaint was constipation with difficult defecation in 33 (83%), followed by rectal pain in 5 (13%), rectal prolapse in 1 (3%), and incontinence in 1 (3%). Previous prostatic surgery had been performed in 16 (40%) patients. The mean age and duration of symptoms were 72.4 years (range, 30–88) and 10.3 years (range, 0.5–70), respectively. Excessive straining during evacuation was noted in 73%, unilateral or bilateral pudendal neuropathy in 24.5%, paradoxical puborectalis contraction in 49% and abnormal EMG in 11% of patients. Higher resting pressures with a mean 3.9 cm high pressure zone were noted in 29% of patients. The accompanying findings in defecography were, non-relaxing or partially relaxing puborectalis muscle (66%), perineal descent (65%), intussusception (23%), and sigmoidocele (15%). None of the patients underwent surgery for rectocele alone. In conclusion, rectocele is uncommon in males; it rarely appears as an isolated dysfunction as it is often associated with functional disorders of the pelvic floor. There is a frequent association between rectocele and prostatectomy. Clinical significance and therapeutic strategy remain unknown.

Recurrent rectal prolapse

PURPOSE: The aim of this study was to assess the clinical and functional outcome of surgery for recurrent rectal prolapse and compare it with the outcome of patients who underwent primary operation for rectal prolapse. METHODS: All patients who underwent surgery for rectal prolapse were evaluated for age, gender, procedure, anorectal manometry and electromyography findings, and morbidity. The results for patients who underwent surgery for recurrent rectal prolapse were compared with a group of patients matched for age, gender, surgeon, and procedure who underwent primary operations for rectal prolapse. RESULTS: A total of 115 patients underwent surgery for rectal prolapse. Twenty-seven patients, 10 initially operated on at this institution and 17 operated on elsewhere, underwent surgery for recurrent rectal prolapse. These 27 patients were compared with 27 patients with primary rectal prolapse operated on in our department. In the recurrent rectal prolapse group, prior surgery included rectopexy in 7 patients, Delormes procedure in 7 patients, perineal rectosigmoidectomy in 7 patients, anal encirclement procedure in 4 patients, and resection rectopexy in 2 patients. Operations performed for recurrence were perineal rectosigmoidectomy in 14 patients, resection rectopexy in 8 patients, rectopexy in 2 patients, pelvic floor repair in 2 patients, and Delormes procedure in 1 patient. There were no statistically significant differences between the groups in preoperative incontinence score (recurrent rectal prolapse, 13.6±7.8vs. rectal prolapse, 12.7±7.2; range, 0–20) or manometric or electromyography findings, and there were no significant differences in mortality (0vs. 3.7 percent), mean hospital stay (5.4±2.5vs. 6.9±2.8 days), anastomotic complications (anastomotic stricture (0vs. 7.4 percent), anastomotic leak (3.7vs. 3.7 percent) and wound infection (3.7vs. 0 percent)), postoperative incontinence score (2.8±4.8vs. 1.5±2.7), or recurrence rate (14.8vs. 11.1 percent) between the two groups at a mean follow-up of 23.9 (range, 6–68) and 22 (range, 5–55) months, respectively. The overall success rate for recurrent rectal prolapse was 85.2 percent. CONCLUSION: The outcome of surgery for rectal prolapse is similar in cases of primary or recurrent prolapse. The same surgical options are valid in both scenarios.

Laparoscopic colectomy yields similar morbidity and disability regardless of patient age.

Abstract This study compared the outcome factors of morbidity and the length of disability in older and younger patients following laparoscopic colorectal surgery. All patients undergoing laparoscopic segmental resection during the study period were included. Morbidity was determined by reviewing the medical records, and disability by a patient-administered questionnaire. The series was divided into two age cohorts (≤64 and ≥65 years), which did not differ significantly in gender or type of procedure. Between these two groups we found no significant differences in mean duration of ileus (3.3 days in both groups), the mean length of hospitalization (5.7 vs. 6.3 days, respectively), morbidity rate (18% vs. 21%), or time until returning to partial activity (1.6 vs. 1.6 weeks) or to full activity (3 vs. 2 weeks). Our findings demonstrate that neither the morbidity rate nor the disability period after laparoscopic techniques differ between elderly and younger patients. We therefore endorse the use of laparoscopy regardless of patient age.

Laparoscopic versus open stoma creation for fecal diversion

Abstract: This study compared the results for laparoscopic and conventional laparotomy techniques of intestinal stoma creation. All patients who underwent only fecal diversion without any other abdominal procedures were included. Neither prior laparotomy, inflammatory bowel diseases, nor recurrent or metastatic carcinoma were absolut contraindications. Parameters evaluated included age, indications, previous abdominal surgery, operative time, time until stoma function, and the length of postoperative hospitalization. Patients were divided into two groups: laparoscopy and laparotomy. Between March 1993 and October 1996, 41 laparoscopic and 11 intestinal stomas by laparotomy were performed for fecal diversion. There were no significant differences between the 2 groups relative to mean age of patients or history of previous abdominal surgery. No significant differences in mean operation time were noted among patients with prior abdominal surgery: laparoscopy group. 98 min vs. laparotomy group, 95 min. Among patients without prior abdominal surgery, the mean operation time was: laparoscopy group, 78 min vs. laparotomy group, 63 min (p = NS). Morbidity rates were not statistically different between the 2 groups. Stomas began to function in the laparoscopic group earliet (2.3 days) than in the laparotomy group (4.5 days) (p<0.05). Similarly, the length of postoperative hospitalization was shorter in the laparoscopic group (5.3 days vs. 7.6 days, p<0.05). Interestingly, at a mean follow-up of 22 months, none of the patients in the laparoscopic group had stoma prolapse vs. 2 patients in the laparotomy group. Laparoscopic stoma construction was accomplished without significantly longer operative time or complications and was associated with earlier function and more rapid hospital discharge than were stomas created by laparotomy. Moreover, in this small group of patients at short follow-up, stoma prolapse has not been observed.

Laparoscopic-assisted surgery for constipation

Abstract: The aim of this study was to evaluate the safety, outcome and disability of various forms of laparoscopic-assisted colectomy for constipation. Between August 1991 and February 1995, 14 patients with constipation who underwent laparoscopic assisted total abdominal colectomy with ileorectal anastomosis (TAC + IR) or sigmoidectomy with colorectal anastomosis (SC + CR) with or without rectopexy were analyzed. Parameters included age, sex, preoperative medical treatment and evaluation, constipation score, indication for surgery, procedure performed, length of surgery, postoperative ileus, and hospitalization as well as morbidity, cosmesis, functional outcome and return to partial and full activity. Surgery was undertaken for colonic inertia (6 patients) and obstructing sigmoidocele with or without prolapse (8 patients) in 12 females and 2 males with a mean age of 47.5 (range 22–77) years. The mean history of laxative- or enema-dependent constipation was 18.3 (range 7–35) years and the mean constipation score was 24.4 (range 20–29). The overall mean operating time was 217.5 (range 125–325) min; 260 (range 195–315) min in the patients with TAC + IR, and 185.6 (range 125–325) min in the patients with SC + CR with or without rectopexy (P < 0.05). The mean length of postoperative ileus was 3.8 (range 2–7) days, and the length of hospitalization was 7.6 (range 4–15) days. There were 3 (21%) cases of intraoperative complications, and 4 cases of (29%) postoperative complications. At a mean follow-up of 37.8 (range 18–60) months, the mean frequency of bowel movements had increased from 2.5 per week preoperatively to 8.4 per week postoperatively (P < 0.0001). Ten patients reported excellent or good results relative to cosmesis. The mean time to return to partial activity was 1.7 (range 1–3) weeks, and return to full activity was 5.1 (range 3–10) weeks. Although laparoscopic procedures for constipation have definite advantages including better cosmesis and more rapid return to partial and full acitivity, disadvantages include the long operating time that may preclude its routine application.