Brooke Gurland

Laparoscopic pancreatic resection: single-institution experience of 19 patients

BACKGROUND The number of laparoscopic pancreatic resections reported in the surgical literature has been remarkably low. Few substantive data are available concerning current indications and outcomes after laparoscopic pancreatectomy. The purpose of this article is to review the recent indications, complications, and outcomes after laparoscopic pancreatic resection. STUDY DESIGN A retrospective analysis of the Mount Sinai hospital records was performed for all patients who underwent laparoscopic distal pancreatectomy or enucleation between the time of the first resection in November 1993 until the time of this study in March 2000. RESULTS In the 19 patients (6 men) the mean age was 53 years (range 22 to 83 years). In 16 patients (84%) the entire procedure was done by laparoscopy; one operation was converted to a hand-assisted technique; and two cases were converted to open. Median operating time was 4.4 hours (range 1.6 to 6.6 hours), and median intraoperative blood loss was 200 mL. Postoperative complications included three pancreatic leaks (16%), one case of superficial phlebitis, and one prolonged ileus for 7 days (total morbidity of 26%). There were no deaths. The median length of postoperative hospital stay was 6 days (range 1 to 26 days). CONCLUSIONS This represents the largest single-institution experience with laparoscopic pancreatic resection. The considerable morbidity rate is comparable to recently published open series, and is likely inherent in pancreatic surgery, rather than the technical approach. Laparoscopic pancreatic surgery resulted in shorter hospital stays and appears to be safe for benign diseases.

Does Rectal Wall Tumor Eradication With Preoperative Chemoradiation Permit a Change in the Operative Strategy

PURPOSEPreoperative chemoradiation may downstage locally advanced rectal cancer and, in some cases, with no residual tumor. The management of complete response is controversial and recent data suggest that radical surgery may be avoided in selected cases. Transanal excision of the scar may determine the rectal wall response to chemoradiation. This study was designed to assess whether the absence of tumor in the bowel wall corresponds to the absence of tumor in the mesorectum, known as true complete response.METHODSA retrospective review of the medical records of patients who underwent preoperative chemoradiation for advanced mid (6–11 cm from the anal verge) and low (from the dentate line to 5 cm from the anal verge) rectal cancer (uT2–uT3) followed by radical surgery with total mesorectal excision was undertaken. Patients in whom the pathology specimen showed no residual tumor in the rectal wall (yT0, “y” signifies pathologic staging in postradiation patients) were assessed for tumoral involvement of the mesorectum.RESULTSA total of 109 patients underwent preoperative, high-dose radiation therapy (94 percent with 5-fluorouracil chemosensitization), followed by radical surgery for advanced rectal cancer. Preoperatively, 47 patients were clinically assessed to have potentially complete response. After radical rectal resection, pathology did not reveal any residual tumor within the rectal wall (yT0) in 17 patients. In two (12 percent) of these patients, the mesorectum was found to be positive for malignancy: one had positive lymph nodes that harbored cancer; one had tumor deposits in the mesorectal tissue.CONCLUSIONSCompete rectal wall tumor eradication does not necessarily imply complete response, because the mesorectum may harbor tumor cells. Thus, caution should be exercised when considering the avoidance of radical surgery. Reliable imaging methods and clinical predictors for favorable outcome are important to allow less radical approaches in the future.

Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

Introduction  Colonic J‐pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch‐anal anastomosis.

Laparoscopic surgery for inflammatory bowel disease: Results of the past decade

Laparoscopic colectomy is one of the most difficult laparoscopic procedures. Surgeons attempting to perform laparoscopic surgery for inflammatory bowel disease (IBD) must have significant experience with IBD and advanced laparoscopic skills. Surgical management for IBD may be treated with a range of laparoscopic procedures that vary in complexity. After 10 years of experience, studies comparing laparoscopy versus laparotomy are favoring laparoscopy when evaluating reduction in postoperative ileus, pain, and length of hospitalization, disability, and cosmesis. The indications and contraindications for laparoscopic surgery for IBD are evolving as surgical expertise and equipment improve.

Surgeons Should Not Hesitate to Perform Episioproctotomy for Rectovaginal Fistula Secondary to Cryptoglandular or Obstetrical Origin

BACKGROUND: Closure of rectoanovaginal fistula from a cryptoglandular or obstetrical origin can be difficult. Multiple techniques exist and none are perfect. Although episioproctotomy offers the advantage of a simultaneous repair of the sphincter complex, it is a more extensive procedure. A rectal-advancement flap appears less traumatic and divides no perineal tissue or sphincter. The aim of this study was to evaluate the results of episioproctotomy and rectal-advancement flap on healing, postoperative continence, and sexual function. METHODS: Data were retrospectively collected regarding 87 women with cryptoglandular or obstetrical rectoanovaginal fistula treated from June 1997 to 2009, who underwent episioproctotomy or rectal-advancement flap at the discretion of the treating surgeon. Healing, use of seton or stoma, number of previous procedures, smoking, age, body mass index, dyspareunia, SF-12 health survey, the IBD Quality of Life, and the Fecal Incontinence Quality of Life, and the Female Sexual Function Index were obtained from our database and via telephone interviews. The Fisher exact probability and &khgr;2 tests were used. RESULTS: The mean age of these 87 women was 42.8 ± 10.5 years. Mean follow-up was 49.2 ± 39.2 months. Fifty (57.5%) patients underwent episioproctotomy and 37 (42.5%) underwent rectal-advancement flap. Thirty-nine (78%) patients healed after episioproctotomy vs 23 (62.2%) patients after rectal-advancement flap (P = .1). Episioproctotomy was associated with significantly better fecal (P < .001) and sexual (P = .04) function. There was no significant difference in other studied variables between the 2 techniques. CONCLUSIONS: Despite episioproctotomy being a more extensive procedure, healing rates were comparable between episioproctotomy and rectal-advancement flaps. In this select population, episioproctotomy may provide better continence and may confer better sexual function compared with rectal-advancement flap. In appropriate patients surgeons should not hesitate to perform episioproctotomy on cryptoglandular or obstetrical-associated rectoanovaginal fistula.

Using technology to improve data capture and integration of patient-reported outcomes into clinical care: pilot results in a busy colorectal unit.

PURPOSE: Patient-reported outcomes are traditionally collected through paper questionnaires. This process is labor intensive and costly. The aim of this study was to assess the feasibility of using tablet computing technology to streamline the questionnaire intake process and integrate patient-reported outcomes into electronic health records for access at the point of care. METHODS: Response-driven electronic questionnaires for patients with colorectal disorders were designed. The impact of this technology on clinical workflow and questionnaire response rates was assessed. Historical data on paper questionnaire response rates over a similar time period were compared with the electronic data. RESULTS: From June through July 2009, data from 103 patient visits to 2 surgeons over 8 clinic days were included. Females comprised 69.7% of the sample with a median age of 49 (range, 18–84) years. When patients checked in 30 minutes early, 82% completed the forms by their scheduled visit time. The questionnaires response rate was 96%. Scores were calculated automatically and included in the electronic health record. Median questionnaire completion time was 15 (interquartile range, 8–21) minutes. Conversely, collection rates of historical data for the same surgeons over a 2-month period revealed that 152 patient visits yielded 38 paper questionnaires, a response rate of 25%. CONCLUSION: Collection of patient-reported outcomes by use of tablet technology and automatic transmission into the electronic chart with data storage for later use is feasible. This process can overcome many of the inefficiencies associated with paper questionnaires.

Overlapping sphincter repair: does age matter?

BACKGROUND: The predictors of the outcomes following anal sphincteroplasty have not been well documented. OBJECTIVE: The aim was to evaluate age as a predictor of functional outcome and quality of life after overlapping sphincter repair. DESIGN: This study is a retrospective review of chart review followed by a prospective evaluation by the use of validated questionnaires. SETTINGS: Patients were assigned to group A (⩽60 years old) or group B (>60 years). PATIENTS: Included were patients with obstetric sphincter injuries who underwent overlapping sphincteroplasty between 1996 and 2007. MAIN OUTCOME MEASURES: The Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, the Cleveland Global Quality of Life scale, and a patient satisfaction questionnaire were used to assess outcome. RESULTS: Three hundred twenty-one women underwent sphincteroplasty and 197 responded to this study, 146 (74.1%) patients in group A and 51 (25.9%) patients in group B. Median follow-up was 7.7 years (range, 4.7–10.0). The mean overall Fecal Incontinence Quality of Life Scale was 11.0 ± 3.5. Median Fecal Incontinence Severity Index score was 29.8 ± 15.9. Mean Cleveland Global Quality of Life scale was 0.7 ± 0.2. The 2 groups were comparable for BMI (p = 1.0), ethnic background (p = 0.8), smoking (p = 0.8), and follow-up duration (p = 0.9). Intergroup comparison showed no significant difference in the Fecal Incontinence Quality of Life Scale scores (p = 0.5) in all subscales: lifestyle (p = 0.8), coping behavior (p = 0.5), depression and self-perception (p = 0.2), and embarrassment (p = 0.1). No significant differences were noted in Fecal Incontinence Severity Index (p = 0.2), Cleveland Global Quality of Life scale (p =1.0), or postoperative satisfaction (p = 0.6). LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: Comparable long-term Fecal Incontinence Severity Index score and Fecal Incontinence Quality of Life Scale scores following overlapping sphincter repair suggest that age is not a predictor of outcome for overlapping sphincter repair. This procedure can be offered to both young and older patients.

Transrectal ultrasound, manometry, and pudendal nerve terminal latency studies in the evaluation of sphincter injuries.

Fecal incontinence may be due to postpartum anal sphincter injuries or neurological damage even in the absence of obvious perineal trauma. Anal physiologic testing with transrectal ultrasound, manometry, and pudendal nerve terminal latency studies help to identify those patients with anal sphincter injuries who might benefit from anal sphincter repair. In this article, the authors discuss the specific tests that are available and how to interpret them.

Ventral Rectopexy for Rectal Prolapse and Obstructed Defecation

Ventral rectopexy has gained popularity in Europe to treat full-thickness rectal external and internal prolapse. This procedure has been shown to achieve acceptable anatomic results with low recurrence rates, few complications, and improvements of both constipation and fecal incontinence. The authors review the principles, techniques, and outcomes of ventral rectopexy.

Ventral mesh rectopexy: is this the new standard for surgical treatment of pelvic organ prolapse?

Diseases of the Colon & ReCtum Volume 57: 12 (2014) Ventral rectopexy (VR) has gained increasing worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. the technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rectal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects. VR avoids the surgical risks associated with anastomotic complications after colon resection and avoids new-onset constipation reported with lateral rectal stalk division and extensive rectal dissection. since D’hoore and Penninckx reported results of laparoscopic VR (lVR) in 2006 from 109 patients, this procedure has been gaining attention in colorectal practices. meta-analysis of 789 patients in 12 published series of lVR report recurrence rates for pelvic organ prolapse at 3.4% (95% Ci 2.0–4.8). Complication rates varied from 14% to 47%. the overall mean decrease in fecal incontinence scores was 44.9% (95% Ci 6.4–22.3). at a median follow up of 29 months (range, 4–59 months), there was a significant decrease in constipation of 23.9% (95% Ci 6.8–40.9). thus, a single operation has the ability to correct multiple anatomic defects associated with vaginal and rectal prolapse, in addition to improving functional symptoms associated with fecal incontinence and constipation. Badrek-al amoudi et al reported their experience in a tertiary care center dealing with complications after lVR. they reported early procedure failure rates related to inadequate ventral dissection or detachment of the proximal mesh by incorrectly placed staples at the sacrum. major mesh complications included rectal stricture (n = 4), rectal vaginal fistula (n = 3), pain/dyspareunia (n = 5), and mesh erosions (rectum = 2, vagina = 8, bladder = 1). lVR is technically demanding and requires a complete ventral dissection of the rectovaginal septum (rectovesical in men) down to the pelvic floor and suturing skills within a confined space that are at their limit. the learning curve for lVR remains unknown, and mackenzie and Dixon report that the proficiency gain curve for the relevant clinical and quality-of-life outcomes was between 82 and 105 cases. Proficiency with respect to operating time was reached at 54 cases. Poor technique minimizes the functional benefit and increases the risk for complications. male patients and those who have undergone previous abdominal operations are more likely to encounter operative complications. sacral discitis is an uncommon complication that can occur after any type of rectopexy or sacral colpopexy where tacks or sutures are applied to secure the mesh at the site of the sacral promontory. in an analysis of 200 patients undergoing VR, Draaisma et al noted 2 patients who experienced mesh infection complicated by discitis at the site of the proximal mesh fixation. Bacterial translocation from the distal rectum to the mesh and, ultimately, to the site of fixation at the sacral promontory may explain this complication. i was an early adopter of VR in the united states. i initially offered this procedure to patients who either developed recurrent rectal prolapse after resection rectopexy or had concomitant vaginal prolapse. We reported our experience with 81 patients (in 2008–2013) undergoing VR. full-thickness prolapse was present in 67 (83%) and internal prolapse in 14 patients (17%). VR was performed robotically in 48 patients (60%), laparoscopically in 18 (22%), open in 11 (13%), and converted in 4 (5%). Biological mesh was used in 54 patients (67%) and synthetic polypropylene mesh in 27 (33%). fifty patients (64%) underwent concomitant gynecologic procedures, and 29 (36%) underwent strictly VR. there were no complications in 51 patients (63%). urinary dysfunction, transient arrhythmia, wound-related issues, and ileus were Ventral Mesh Rectopexy: Is This the New Standard for Surgical Treatment of Pelvic Organ Prolapse?