Bruce A. Orkin

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery, or TEM, is a technique that can be used for the treatment for early staged rectal cancer. This technique utilizes carbon dioxide insufflation through a 40 mm rectoscope to create better endoscopic visualization of the operative field. TEM has been praised for its access to middle and upper-third rectal cancers. However, one limitation of TEM is its inability to address local lymph node involvement. Therefore, an adequate preoperative assessment is crucial before using TEM as a curative modality. TEM can be used to remove virtually any benign lesion that can be brought into view. In addition, there are several studies that have shown TEM is a safe and effective way to treat T1 cancers and may have a role in the treatment of T2 and T3 cancers when combined with radiation and chemotherapy. TEM has lower recurrence rates, faster recovery, and fewer complications when compared to other local excision techniques and radical surgeries. The future of TEM is growing in acceptance as more surgeons learn to master this technique.

Small Bowel Obstruction: Conservative vs. Surgical Management

PURPOSEThe aim of this study was to assess incidence, risk factors, and recurrence rates for conservative and surgical management of small bowel obstruction.METHODSRetrospective chart review was conducted of 329 patients accounting for 487 admissions with small bowel obstruction. Data were obtained from the institutional database and patient charts. Patients with early recurrent small bowel obstruction had prior operations or hospitalization with conservative therapy for small bowel obstruction, then had a hospital stay >10 days following abdominal surgery because of obstruction or required readmission for small bowel obstruction within 30 days. Patients treated for prior small bowel obstruction and then readmitted after 30 days for a recurrent small bowel obstruction were classified as having late recurrent small bowel obstruction.RESULTSA total of 329 patients with a diagnosis of small bowel obstruction were identified. At index admission, 43 percent (142) were successfully treated conservatively, whereas 57 percent (187) failed conservative treatment and underwent surgery. Overall, there were eight early deaths, four in each group (2.8 percent conservative vs. 2.1 percent surgical; no significant difference). The frequency of recurrence for those treated nonoperatively was 40.5 percent compared with 26.8 percent for patients treated operatively (P < 0.009). Patients treated without operation had a significantly shorter time to recurrence (mean, 153 vs. 411 days; P < 0.004) and had fewer hospital days for their index small bowel obstruction (4.9 vs. 12.0 days; P < 0.0001). Two hundred one (63 percent) patients had abdominal surgery and 119 (37 percent) patients had no prior abdominal surgery before developing a small bowel obstruction. Previous abdominal operations by procedure type were colorectal surgery (34 percent), gynecologic surgery (28 percent), exploratory laparotomy (20 percent), appendectomy (14 percent), cholecystectomy (12 percent), herniorraphy (8 percent), and gastric bypass (5 percent). The mean time interval between initial procedure and index small bowel obstruction was 1.3 years for gastric bypass, 6.1 years for herniorraphy, 7.8 years for exploratory laparotomy, 8 years for cholecystectomy, 8.4 years for colorectal surgery, 11.8 years for gynecologic surgery, and 22.5 years for appendectomy. There was no significant difference between early and late recurrent small bowel obstruction in patients treated nonoperatively or operatively, regardless of prior history of abdominal surgery. Logistic regression analysis failed to identify any specific risk factors that were predictors of the success of conservative or surgical management.CONCLUSIONSOperatively treated patients had a lower frequency of recurrence and a longer time interval to recurrence; however, they also had a longer hospital stay than that of patients treated nonoperatively. There was no significant difference in treatment type or in incidence or type of prior surgery among patients with early and late small bowel obstruction. None of the variables analyzed in this study were significant predictors of the success of a particular treatment.

Excellent outcome using selective criteria for rectocele repair

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16–78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1–8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5–64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test,P< 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

HIV-positive patients with anal carcinoma have poorer treatment tolerance and outcome than HIV-negative patients

PURPOSE: Anal carcinoma is being found in HIV-positive patients with increasing frequency. Most patients are treated with combined chemotherapy and radiation. It was our impression that HIV-positive patients do not fare as well as HIV-negative patients in terms of both response to and tolerance of therapy. METHODS: To test this hypothesis, we reviewed our experience with anal carcinoma and compared HIV-positive to HIV-negative patients by age, gender, sexual orientation, stage at diagnosis, treatment rendered, response to treatment, tolerance, and survival. From 1985 to 1998, 98 patients with anal neoplasms were treated. Seventy-three patients had invasive squamous-cell carcinoma (including cloacogenic carcinoma), and this cohort was analyzed. Thirteen patients were HIV positive and 60 were HIV negative. RESULTS: The HIV-positive and HIV-negative groups differed significantly by age (42vs. 62 years,P<0.001), male gender (92vs. 42 percent,P<0.001), and homosexuality (46vs. 15 percent,P<0.05). There were no differences by stage at diagnosis or radiation dose received. Acute treatment major toxicity differed significantly (HIV positive 80 percentvs. HIV negative 30 percent;P<0.005). Only 62 percent of HIV-positive patients were rendered disease free after initial therapyvs. 85 percent of HIV-negative patients (P=0.11). Median time to cancer-related death was 1.4vs. 5.3 years (P<0.05). A survival model did not show age, gender, stage, or treatment to be independent predictors. CONCLUSION: We found that HIV-positive patients with anal carcinoma seem to be a different population from HIV-negative patients by age, gender, and sexual orientation. They have a poorer tolerance for combined therapy and a shorter time to cancer-related death. A strong trend to poorer initial response rate was also seen. These results suggest that the treatment of HIV-positive patients with anal carcinoma needs to be reassessed.

THE BEST OPERATION FOR RECTAL PROLAPSE

Rectal prolapse remains a disorder for which the cause is not clearly understood and the best method of management is debated. Because the natural history of prolapse frequently leads to complications of incontinence and constipation, we believe that all patients presenting with internal and external prolapse should be considered for repair. Although the type of operative repair recommended may vary, it is clear that all patients with external rectal prolapse should be offered some type of repair. What is not clear from the literature is the appropriate management of those patients with internal prolapse. As shown in the George Washington University experience, surgery is rarely performed for isolated internal prolapse. Most patients who present with internal prolapse also have an associated enterocele, rectocele, or cystocele. Repair of the internal prolapse and the associated disorder may benefit many of these patients. If internal prolapse is an isolated finding, it is not clear to what extent the prolapse is responsible for the patients symptoms, and repair is generally not advised. These guidelines are easy to enumerate but may be difficult to practice in some patients. Therefore, ongoing evaluation of clinical results is critical to improve our understanding of these disorders. This discussion has outlined the current theories of the cause of rectal prolapse, the symptoms and findings patients present with, and the possible approaches to repair.

Extended resection for locally advanced primary adenocarcinoma of the rectum

To determine the perioperative mortality and morbidity and the long-term prognosis of patients undergoing extended pelvic resections for localized advanced primary adenocarcinoma of the rectum, the authors reviewed their experience with 65 patients operated on between 1956 and 1984. Local invasion without distant metastasis was present in all patients at operation anden bloc resection of all involved organs was performed with intent of cure. Average age at operation was 61 years; 15 (23 percent) were men and 50 (77 percent) were women. Operations included abdominoperineal resection in 37 patients (57 percent), low anterior resection in 20 patients (31 percent), and Hartmann procedure in 8 patients (12 percent). Additionally, 34 of 42 women (81 percent) with intact uteri underwenten bloc hysterectomy, 37 of 48 women (77 percent) with intact ovaries had oophorectomy, and 25 of 50 women (50 percent) had partial vaginal resection. Seventeen of the 65 patients (26 percent) had a cystectomy, and 2 patients had a portion of small intestine resected in continuity with their tumor. Pathologic examination revealed lymph node involvement in 29 patients (45 percent) and histologic confirmation of adjacent organ extension in 37 patients (57 percent). There were no perioperative deaths, the average survival was 5.7 years, and 25 patients (38 percent) were alive after a mean follow-up period of 9.3 years. Overall five-year survival was 52 percent. Forty patients died during the follow-up period, with 26 (65 percent) of the deaths attributable to either recurrent carcinoma (25 patients) or a new primary lesion (1 patient). The cumulative probability of tumor recurrence at five years was 39 percent.

Thrombosed external hemorrhoids: outcome after conservative or surgical management.

PURPOSE:Few data exist on the actual recurrence rates of thrombosed external hemorrhoids. We wished to determine the incidence of recurrence, intervals to recurrence, and factors predicting recurrence of thrombosed external hemorrhoids after conservative or surgical management.METHODS:Two hundred and thirty-one consecutive patients with thrombosed external hemorrhoids treated from 1990 to 2002 were identified. Recurrence was defined as complete resolution of the index lesion with subsequent return of a thrombosed external hemorrhoid and did not include patients with chronic symptoms. Data were gathered retrospectively. Multiple potential risk factors were reviewed.RESULTS:The index thrombosed external hemorrhoid was managed conservatively in 51.5 percent of cases and surgically in 48.5 percent. There were no differences between groups in gender, age, or race, and 44.5 percent of all patients had a prior history of thrombosed external hemorrhoid. A prior history was less common in the conservative group than in the surgical group (38.1 percent vs. 51.3 percent; P < 0.05). The frequency of pain or bleeding as the primary complaint was higher in the surgical group (P < 0.001 and P < 0.002). In addition, the surgical group was more likely to report all three symptoms of pain, bleeding, and a lump (P < 0.005). Mean follow-up was 7.6 months, with the range extending to 7 years. Time to symptom resolution averaged 24 days in the conservative group vs. 3.9 days in the surgical group (P < 0.0001). The overall incidence to recurrence was 15.6 percent—80.6 percent in the conservative group vs. 19.4 percent in the surgical group. The rate of recurrence in the conservative group was 25.4 percent (4/29; 14 percent were excised) whereas only 6.3 percent of the surgical patients had recurrence (P < 0.0001). Mean time to recurrence was 7.1 months in the conservative group vs. 25 months in the surgical group (P < 0.0001). Survival analysis for time to recurrence of thrombosed external hemorrhoid indicated that time to recurrence was significantly longer for the surgical group (P < 0.0001). Logistic regression analysis of multiple factors (including diverticular disease, constipation, straining, benign prostatic hypertrophy, diarrhea, skin tags, history of travel, anoreceptive sex, anal fissures, internal hemorrhoids, and obesity) was performed to determine the outcome of each group. None of these variables were significant predictors of recurrence.CONCLUSIONS:Patients whose initial presentation was pain or bleeding with or without a lump were more like to be treated surgically. Surgically treated patients had a lower frequency of recurrence and a longer time interval to recurrence than conservatively treated patients. None of the variables analyzed were significant predictors of a particular treatment, except for a prior history of thrombosed external hemorrhoids, which may represent patient choice. Although most patients treated conservatively will experience resolution of their symptoms, excision of thrombosed external hemorrhoids results in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals.

The Rectal Motor Complex

To identify patterns of motility in the rectum of humans during the day while awake and at night during sleep, and to correlate the patterns with interdigestive duodenal motor complexes and sleep cycles, intraluminal rectal pressure was recorded in 12 healthy subjects (five female, seven male; mean age, 28 years) using a flexible, noncompliant, silastic catheter and an Arndorfer system with a single perfused rectal port 6 cm above the anorectal junction, duodenal motility was recorded via a perfused oroduodenal tube, and sleep stages were determined electroencephalographically. Discrete bursts of rectal motor waves, called rectal motor complexes (RMCs), were identified on 72 occasions in 11 of the 12 subjects during 157 hours of recording. The RMCs were found in daytime during fasting or after feeding (0.2 ± 0.1 RMCs/hour), but were more easily and frequently identified at night during sleep (0.8 RMCs/hour, p < .01). The complexes had a distinct onset, a mean duration ± SEM of 9.5 ± 1.0 minutes, and a distinct decline. Within each complex, the waves had a mean frequency of 3.8 ± 0.3 per minute and a mean amplitude of 19 ± 2.7 mm Hg. Complex‐to‐complex intervals at night averaged 74 ± 15 minutes. No clear‐cut temporal association was present between the complexes and phase III of interdigestive duodenal motor complex or the REM stage of sleep.

The digital rectal examination scoring system (DRESS).

PURPOSE: Assessment of anal sphincter tone is a critical part of anorectal examination, yet no standardized, quantifiable method for describing anal sphincter tone on digital rectal examination exists. We developed a novel scoring system for anal sphincter tone using a scale of 0 to 5 for both resting pressure and squeeze pressure. The score ranges from 0 = no discernable pressure to 5 = extremely tight and 3 = normal. We hypothesized that the digital rectal examination scoring system (DRESS) score would correlate with anorectal manometry pressures. METHODS: Three hundred three patients (mean age, 51 y; range, 28–86 y) who had a DRESS score and a concurrent manometry test (1998–2008) were identified from a prospective database. Means of 4 quadrant manometry at rest and with squeeze were compared with the resting pressure and squeeze pressure DRESS scores at each point from 0 to 5. Box plots for manometry results by DRESS score were graphed. ANOVA using a significance level of &agr; = .05 tested whether each of the DRESS scores were different from one another. Spearman rank correlation coefficients assessed associations between manometry and DRESS results. RESULTS: Manometric pressures (mmHg; mean ± SEM) for DRESS resting pressure values 0 to 5 were 20.6 ± 2.1, 38.5 ± 2.0, 47.8 ± 1.6, 72.3 ± 1.5, 94.4 ± 2.9, and 128.0 ± 6.7, respectively. Pressures for DRESS squeeze pressure values 0 to 5 were 45.9 ± 5.6, 66.5 ± 3.2, 108.2 ± 4.9, 156.3 ± 4.5, 238.6 ± 9.8, and 368.2 ± 49.1. Box plots demonstrated clear differences between each DRESS score and positive progression from 0 to 5 for both resting pressure and squeeze pressure. ANOVA analysis showed a significant difference in mean manometry measurements at all levels of digital rectal examination, both for resting pressure and squeeze pressure (P < .001). Spearman rank correlations showed a strong positive correlation between the DRESS values and manometry pressures with coefficients of 0.82 for resting pressure and 0.81 for squeeze pressure. CONCLUSIONS: The DRESS score correlated very well with manometry pressures for resting pressure and squeeze pressure. The DRESS system may be a useful description of anal sphincter resting pressure and squeeze pressure in the clinical setting. Further validation may support adoption of the DRESS system as part of the standard anorectal examination.

Which physiologic tests are useful in patients with constipation

PURPOSE: Physiologic tests such as manometry, colonic transit times, balloon compliance, defecography, pudendal nerve latency, and electromyography are used to evaluate patients with severe constipation. Patients referred because of severe constipation between 1991 and 1996 were studied to examine the role that physiologic testing played in making a diagnosis and directing treatment. METHODS: Of 139 patients referred for severe idiopathic constipation, physiologic testing was recommended in 127, and 104 patients underwent the studies. The pretesting impression was noted, and test results were evaluated to determine diagnostic accuracy. If a specific initial impression was documented, tests were classified as refuting it, confirming it or confirming and adding significant information. If there was no clear pretest impression, tests were evaluated for their ability to indicate a diagnosis. The patients history also was evaluated to determine what information was most useful in making a diagnosis. Historical features including duration of constipation, symptoms consistent with outlet obstruction or dysmotility, age, associated urinary incontinence, and prior hysterectomy were analyzed. Data were collected prospectively, then reviewed by an independent observer. RESULTS: Ninety-eight study patients remained after 29 were excluded who did not undergo the recommended studies (19) or because no initial impression was documented (10). In 43 patients (44 percent), testing did not provide additional useful information. In 8 patients, testing confirmed the initial impression and added information impacting the treatment plan. Test results clearly refuted the initial impression in only one patient. In 46 (47 percent) patients the initial impression was uncertain, and in 43 (94 percent) of these, testing aided in making the diagnosis. In three cases, the diagnosis remained uncertain after testing. Prior hysterectomy (P=0.003), urinary incontinence (P<0.001), and symptoms of pelvic outlet obstruction (P=0.03) were associated with a high incidence of rectocele. Defecography and transit times were the most useful tests. Surprisingly, symptoms of outlet obstruction or dysmotility did not show an overall correlation with transit times. CONCLUSIONS: In one-half of these patients with severe constipation, physiologic testing added significant information, leading to a specific diagnosis. Pretesting history and symptoms did not predict which patients were most likely to benefit from these studies.