David J. Maron

Inflammatory Bowel Disease in the Obese Patient

Obesity is becoming increasingly more common among patients with inflammatory bowel disease. In this review, we will explore the epidemiological trends of inflammatory bowel disease, the complex interplay between the proinflammatory state of obesity and inflammatory bowel disease, outcomes of surgery for inflammatory bowel disease in obese as compared with non-obese patients, and technical concerns pertaining to restorative proctocolectomy and ileoanal pouch reservoir, stoma creation and laparoscopic surgery for inflammatory bowel disease in obese patients.

Outcomes of Reimplantation of the Artificial Bowel Sphincter.

BACKGROUND: Outcomes of artificial bowel sphincter reimplantation for severe fecal incontinence remain unknown. OBJECTIVE: The purpose of this study was to evaluate the feasibility and outcomes of artificial bowel sphincter reimplantation versus implantation. DESIGN: This was a retrospective review study. SETTINGS: The study was conducted at a single institution. PATIENTS: Patients with severe incontinence who underwent de novo implantation and re-implantation between January 1998 and December 2012 were included. MAIN OUTCOME MEASURES: Complications, length of functional device time, success rates (functioning device at follow-up), patient demographics, comorbidities, etiology of incontinence, operative data, postoperative complications, and outcomes of initial implantation versus reimplantation were analyzed. RESULTS: A total of 57 patients (mean age, 49.3 ± 13.5 years; 44 women) underwent implantation. Sixteen (28%) succeeded and 41 (72%) failed, requiring explantation; 17 of 41 patients underwent reimplantation; 5 had 2 reimplantations. There were 79 implantations and 50 explantations (63.3%) in total. Implantation and reimplantation procedures had similar lengths of operation, hospital stay, postoperative complications, and explantation rate. Most common reasons for device explantation were infection/erosion (27/50 (54%)) and malfunction (19/50 (38%)). Reasons for reimplantation included device malfunction/migration (17/22 (77.3%)) and/or infection/erosion (5/22 (22.7%)). Seven (41.2%) of 17 patients for whom reimplantation was attributed to noninfectious reasons had a functioning device, whereas only 1 (20.0%) of 5 who had reimplantation because of infection/erosion had a working device. At a median follow-up of 29.5 months (range, 1.0–215.0 months), 24 patients (42%) retained a functioning device (implantation = 16; reimplantation = 8). Success rates were not significantly different between initial implantation and reimplantation procedures (p = 0.755). There were no differences in the length of functional device time between implanted and reimplanted devices (p = 0.439). LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: Artificial bowel sphincter implantation has a high failure rate, requiring explantation in 72% of patients in this study. Reimplantation was often possible, with a success rate of 47%. Selected reimplantation for noninfectious complications had better outcomes than did reimplantation for septic causes. Short- and long-term outcomes are comparable to initial implantation.

Redo sphincteroplasty: are the results sustainable?

Objective: This study aimed to investigate the long-term outcomes of patients who undergo redo sphincteroplasty (RS). Methods: Patients with fecal incontinence (FI) who underwent RS between November 1988 and December 2011 were retrospectively identified from a prospective database. A questionnaire and telephone survey assessed current Cleveland Clinic Fecal Incontinence Score (CCFFIS; best 0, worst 20) and Fecal Incontinence Quality of Life (FIQoL; best 4.1, worst 1) scale. Success was defined as no further continence surgery, no stoma and CCFFIS <9 at completion of follow-up. The Wilcoxon and Mann-Whitney U tests were used for comparing quantitative variables. Bivariate logistic regression analysis was done to identify predictive factors for success. Results: Fifty-six (66.7%) of 84 patients who underwent RS were available for evaluation at a median follow-up of 74 (range: 12–283) months. The mean CCFFIS decreased from 16.5 ± 3.7 to 11.9 ± 6.6 (P < 0.001) at last follow-up. Twelve patients (21.4%) underwent further continence surgery for failed sphincteroplasty, three (5.4%) of whom had a permanent stoma. Eighteen patients (32.1%) had a CCFFIS <9 at the completion of follow-up, and 16 (28.6%) had long-term success. Twenty-four patients evaluated for FIQoL had a mean value of 2.6 (range: 1.0–4.1). Postoperative CCFFIS was correlated with FIQoL (Spearman’s correlation coefficient = −0.854, P < 0.001). Logistic regression analysis did not reveal any significant predictive variables for success of RS. Conclusion: Based on our criteria for success, the long-term success rate for RS over a median of 74 months is poor.

Surgical outcomes and their relation to the number of prior episodes of diverticulitis.

Purpose: We aimed to investigate the relationship between the number of prior episodes of diverticulitis and outcomes of sigmoid colectomy. Methods: After institutional review board approval, a retrospective review was undertaken based on records of patients who underwent sigmoid resection with anastomosis for diverticulitis between 4 May 2007 and 29 February 2012. Patients were divided into two groups: 0–3 attacks (group 1) and ≥4 attacks (group 2). Statistical analyses were performed to determine whether the groups differed on demographic, intra-operative and postoperative variables. Results: We identified 247 patients who underwent sigmoid colectomy for diverticulitis (45 open, 202 laparoscopic). The two groups did not differ significantly in age, gender, American Society of Anesthesiologists score, past surgical history, body mass index, length of stay, use of a stoma or number of prior hospitalizations for diverticulitis. Group 1 had a higher rate of abscesses (30.6 vs 6.8%, P < 0.001) and fistulas (19.4 vs 0.9%, P < 0.001); a longer operative time (190.1 vs 166.3 min, P = 0.0024); and higher rates of postoperative complications (45.8 vs 23.3%, P < 0.001) and conversion (17.1 vs 4.4%, P = 0.0091). The most common surgical complications in groups 1 and 2 were wound infection (35 vs 10) and ileus (20 vs 8). Based on multivariate regression analysis, ≥4 attacks were independently correlated with a lower complication rate (odds ratio = 0.512, 95% confidence interval = 0.266–0.987, P = 0.046). Conclusions: Patients who had ≥4 previous attacks of diverticulitis had fewer postoperative complications.

Surgical Treatment of Dysmotility Disorders of the Colon

Abstract Although only a small group of patients may benefit from surgical intervention, the evaluation of these patients must be extensive to ensure both the inclusion of appropriate candidates and the exclusion of inappropriate ones. In addition, the psychologic status of these patients requires thorough assessment and often requires treatment. Through careful testing and selection, satisfactory results can be obtained in more than 90% of patients. However, patients must understand that, although bowel frequency will improve and dependence on laxatives will be eliminated or significantly reduced, other symptoms such as abdominal bloating and pain may persist, develop anew, or become exacerbated. Patients must also understand that they may eventually require a stoma.

Laparoscopy for Benign Diseases of the Colon

Abstract Laparoscopic surgery has revolutionized the delivery of care to the surgical patient undergoing colorectal resection. Since the first laparoscopic‐assisted colectomy in 1991, significant advances have been made in minimally invasive colorectal surgery. For many benign conditions, laparoscopic colectomy has been proven to be safe and effective, and in some instances superior when compared with open surgery. Complex laparoscopic resections such as those for diverticulitis and inflammatory bowel disease have also been shown to have equivalent outcomes when compared with open surgery. Short‐term benefits of a minimally invasive approach include less pain, decreased rates of wound infection and postoperative morbidity, faster return of bowel function, and shorter length of stay. Improvements in long‐term complications have also been noted with lower incidence of incisional hernias and small bowel obstructions secondary to adhesions. As surgeons become more facile with laparoscopic resection, more complex cases such as those for complicated diverticulitis and reoperative surgery for inflammatory bowel disease can be completed with shorter operative times and decreased cost.

Carcinoids, GISTs, and Lymphomas of Colon and Rectum

Less common tumors of the colon and rectum include carcinoids, gastrointestinal stromal tumors, and gastrointestinal lymphomas. Carcinoids are of neuroectodermal origin and frequently secrete bioactive compounds such as serotonin and histamine. Carcinoids that have metastasized to the liver may cause systemic symptoms referred to the carcinoid syndrome. Treatment of carcinoid tumors is surgical resection; however, the type of resection is dependent on the size and location of the tumor. Adjuvant treatment of carcinoid tumors involves the use of somatostatin analogues. Gastrointestinal stromal tumors occur less frequently in the colon and rectum than in other organs of the intestinal tract, but may be detected during endoscopic evaluation of the colon. Surgical treatment of GISTs also depends on the size and location of the tumor. Adjuvant treatment with imatinib (a tyrosine kinase inhibitor that blocks KIT activation) has been shown to reduce the risk of recurrence. The gastrointestinal tract is the most common site of extranodal lymphoma. Treatment typically involves a combination of surgical resection and systemic chemotherapy.

Laparoscopy in Pregnant Patients

The need for abdominal surgery in the pregnant patient is not uncommon. The indication for non-obstetrical surgery during pregnancy should be approached in a similar fashion to the nonpregnant patient. While laparotomy has traditionally been used to address surgical disorders of the peritoneal cavity, the use of laparoscopy is a safe approach with many advantages and should be utilized, when appropriate. An understanding of the physiologic changes that occur during pregnancy is important to the operating surgeon, and anatomic alterations within the abdominal cavity will affect port placement. Proper patient positioning and fetal monitoring are also important in helping to prevent fetal loss during surgery. This chapter will discuss the use of laparoscopy in the pregnant patient with surgical disorders affecting the colon and rectum.

Preoperative Planning and Postoperative Care in Minimal Invasive Colorectal Surgery

Many of the general principles that have been learned from open colon and rectal surgery can be applied to laparoscopic and robotic surgery. Patients undergoing minimally invasive colorectal surgery need a full history and physical exam, with particular attention paid to the number and types of previous abdominal surgeries, as well as any history of any significant abdominal infection. This should be accompanied by appropriate blood work, electrocardiogram, chest x-ray, and other investigations as dictated by the patient’s age and comorbidities. For patients with colon and rectal cancer, routine preoperative evaluation includes preoperative staging and assessment of resectability, as well as a full colonoscopy to rule out synchronous lesions.

Approaches to Failed Rectal Prolapse Surgery

This chapter outlines the Cleveland Clinic’s (Florida) approach to recurrent rectal prolapse. It is recognized that the primary surgical treatment of full-thickness rectal prolapse (let alone its recurrence) is controversial, with a changing paradigm toward more laparoscopic and robot-assisted approaches in patients who were previously poor candidates for abdominal surgery. In this environment the place of perineal surgery is changing. Specialist considerations are required in recurrent cases with residual incontinence, where the role of endoanal stapled rectal resections is currently unclear.