Eric G. Weiss

Is early oral feeding safe after elective colorectal surgery ? A prospective randomized trial

IntroductionThe routine use of a nasogastric tube after elective colorectal surgery is no longer mandatory. More recently, early feeding after laparoscopic colectomy has been shown to be safe and well tolerated. Therefore, the aim of our study was to prospectively assess the safety and tolerability of early oral feeding after elective “open” abdominal colorectal operations. Materials and MethodsAll patients who underwent elective laparotomy with either colon or small bowel resection between November 1992 and April 1994 were prospectively randomized to one of the following two groups: group 1: early oral feeding–all patients received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated; group 2: regular feeding–all patients were treated in the “traditional” way, with feeding only after the resolution of their postoperative ileus. The nasogastric tube was removed from all patients in both groups immediately after surgery. The patients were monitored for vomiting, bowel movements, nasogastric tube reinsertion, time of regular diet consumption, complications, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 mL occurred in the absence of bowel movement. Ileus was considered resolved after a bowel movement in the absence of abdominal distention or vomiting. ResultsOne hundred sixty-one consecutive patients were studied, 80 patients in group 1 (34 maies and 46 females, mean age 51 years [range 16–82 years]), and 81 patients in group 2 (43 males and 38 females, mean age 56 years [range 20–90 years]). Sixty-three patients (79%) in the early feeding group tolerated the early feeding schedule and were advanced to regular diet within the next 24 to 48 hours. There were no significant differences between the early and regular feeding groups in the rate of vomiting (21% vs. 14%), nasogastric tube reinsertion (11% vs. 10%), length of lieus (3.8 ± 0.1 days vs. 4.1 ± 0.1 days), length of hospitalization (6.2 ± 0.2 days vs. 6.8 ± 0.2 days), or overall complications (7.5% vs. 6.1%), respectively, (p = NS for all). However, the patients in the early feeding group tolerated a regular diet significantly earlier than did the patients in the regular feeding group (2.6 ± 0.1 days vs. 5 ± 0.1 days; p < 0.001). ConclusionEarly oral feeding after elective colorectal surgery is safe and can be tolerated by the majority of patients. Thus, it may become a routine feature of postoperative management in these patients.

Is obesity a high-risk factor for laparoscopic colorectal surgery?

BackgroundThe aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures.MethodsAll 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality.ResultsThirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p=0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% vs 24% in the nonobese group (p<0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs 7.6% (p<0.01) and 12.9 vs 3.1%. (p=0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p=0.02).ConclusionLaparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.

Endorectal advancement flap: are there predictors of failure?

PURPOSE The management of complex perianal fistulas with endorectal advancement flap is aimed at avoiding the risk of sphincter injury associated with traditional surgical methods. Long-term follow-up is required to assess the recurrence and continence outcomes of this procedure. The aim of this study was to review our experience with endorectal advancement flap in the treatment of complex perianal fistulas and to define the predictors of successful healing. METHODS A retrospective chart review of all patients who underwent endorectal advancement flap for complex perianal fistulas between 1988 and 2000 was performed. Follow-up was established by telephone interview. RESULTS One hundred six consecutive endorectal advancement flap procedures were performed on 94 patients (94.4 percent). There were 56 females (59.6 percent). Mean age was 41.6 (range, 18–76) years. Cryptoglandular disease was the most common cause of fistula (n = 41, 43.6 percent), followed by Crohn’s disease (n = 28, 29.8 percent). At a mean follow-up of 40.3 (range, 1–149) months, the procedure was successful in 56 (59.6 percent) of 94 patients. Twelve patients underwent repeat surgery with the same technique because of initial failure, 8 of whom eventually healed. Crohn’s disease was associated with a significantly higher recurrence rate (57.1 percent) when compared with fistulas in patients without Crohn’s disease (33.3 percent, P < 0.04). Prior attempts at repair of the fistula were not associated with less favorable outcome of the procedure (P = 0.5). Recurrence was not associated with the type of fistula, origin, preoperative steroid use, postoperative bowel confinement, use of postoperative antibiotics, or creation of a diverting stoma. The median time to recurrence was 8 (range, 1–156) weeks; there was no postoperative mortality. Two patients had postoperative bleeding, one requiring resuture of the flap on the first postoperative day. Recurrences were observed in 15.7 percent of the patients 3 or more years after the repair. In 8 patients (9 percent), continence deteriorated after the endorectal advancement flap, a more common finding in patients who had undergone previous surgical repairs (P < 0.02). CONCLUSION The success rate of endorectal advancement flap for complex perianal fistulas is modest. Failure is mainly correlated with the presence of Crohn’s disease.

Laparoscopic surgery for diverticulitis

AbstractBackground: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. Methods: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p= NS). Results: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). Conclusion: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment.

Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions.

AIM: The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery. METHODS: All eligible patients were prospectively randomized to receive either 4 1 of standard polyethylene glycol (PEG) solution or 90 ml of sodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxons rank-sum test and Fishers exact test. RESULTS: Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaP solutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P<0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17vs.32 percent;P<0.0002), less abdominal pain (12vs.22 percent;P=0.004), less bloating (7vs.28 percent), and less fatigue (8vs.17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P<0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P<0.0001). For quality of cleansing, surgeons scored NaP as “excellent” or “good” in 87 compared with 76 percent after PEG (P=not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P=not significant). CONCLUSION: Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Laparoscopic vs. open abdominoperineal resection for cancer.

PURPOSE: The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer. METHODS: Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow-up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent). RESULTS: Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24vs. 8 percent;P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7vs. 12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan-Meier curves, with median follow-up of 19 and 24 months, respectively (P=0.22; log rank). CONCLUSION: Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long-term outcome of cancer treatment.

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.

Determinants of Recurrence After Sigmoid Resection for Uncomplicated Diverticulitis

AbstractPURPOSE: This study aimed to evaluate the impact of surgery-associated variables on recurrence rates after sigmoid resection for diverticulitis. METHODS: Patients who underwent elective sigmoid resection for uncomplicated diverticulitis between 1992 and 2000 at two tertiary referral centers were followed up for recurrent disease as the primary end point. Recurrence after surgery was defined as left lower quadrant pain, fever, and leukocytosis, with consistent CT and/or contrast enema findings on admission and after six weeks. A logistic regression of the following variables was undertaken: patient demographics, duration of preoperative symptoms, previous admissions and abdominal surgery, surgical access (laparoscopic or open), postoperative complications, splenic flexure mobilization, anastomotic technique (handsewn or stapled), specimen length, inflammation at proximal resection margin, and anastomotic level (colosigmoid or colorectal). The last three variables were defined by the pathologist. Anastomosis level was based on muscle layer configuration (taeniae coli) at the distal resection margin. RESULTS: Two hundred thirty-six patients (105 females) with a mean age of 60.4 (standard deviation, ± 10) years were available for follow-up at 67 ± 30 (range, 11–130) months. The median duration of preoperative symptoms was 18 (range, 12–120) months. All but one (99 percent) patient had at least one admission before surgery. One hundred forty (59 percent) and 96 (41 percent) patients underwent laparoscopic or open resection, respectively. The conversion rate was 13 percent (18 patients) in the former group and the 30-day complication rate was 23 percent, with 0.4 percent 30-day mortality and a 2.1 percent reoperation rate. The splenic flexure was mobilized in 109 patients (47 percent). Anastomoses were fashioned by stapler in 171 patients (73 percent) and were to the rectum in 143 patients (72 percent). Specimen length was 17.9 ± 5.9 (range, 9–47) cm with inflammation at the proximal margin in 30 patients (14 percent). Twelve (5 percent) patients developed a recurrence at a mean of 78 ± 25 (range, 34–109) months with reoperation in one (0.4 percent). The level of anastomosis was the only predictor of recurrence in regression analysis (P = 0.033). Patients with colosigmoid anastomosis had a four times higher risk of having a recurrence compared with patients with colorectal anastomosis (odds ratio, 95 percent confidence interval = 1.12, 14.96). CONCLUSION: Colorectal (rather than colosigmoid) anastomosis was the single predictor of lower recurrence rates after elective sigmoid resection for uncomplicated diverticulitis.

Gracilis Muscle Interposition for the Treatment of Rectourethral, Rectovaginal, and Pouch-vaginal Fistulas : Results in 53 Patients

Background:The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. Material and Methods:A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). Results:Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1–4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohns disease-associated fistulas successfully healed; 75% without Crohns successfully healed. Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1–3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. Conclusion:The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Fibrin Glue Sealing in the Treatment of Perineal Fistulas

AbstractPURPOSE: The surgical management of complex perineal fistulas, such as high transsphincteric and suprasphincteric fistulas, or those associated with Crohn’s disease, radiotherapy, surgical trauma, or cavity or a secondary tract, is associated with the risk of sphincter injury and significant discomfort. Fibrin glue may close fistula tracts without muscle division. Therefore, the aim of this study was to evaluate the use of fibrin glue sealing in treatment of perineal fistulas. METHODS: A retrospective chart review of all patients in whom fibrin glue was used for the treatment of perineal fistula was performed. Patients were contacted by telephone to establish follow-up. RESULTS: Thirty-seven patients underwent injection of fibrin glue for complex perineal fistulas. Twenty-four patients had fibrin glue injection as the principal treatment for the perineal fistula, and 13 had fibrin glue in conjunction with an endorectal advancement flap. The fistula was of cryptoglandular origin in 16 (42 percent) cases and associated with Crohn’s disease and trauma in 7 (19 percent) and 14 (38 percent) patients, respectively. At a mean follow-up of 12.1 months, healing occurred in only 15 (41 percent) patients. The healing rate was 33 percent when fibrin glue was the principal treatment, and 54 percent when used with an endorectal advancement flap. Fistulas of noncryptoglandular origin had a higher success rate, although this difference did not reach statistical significance. There was no morbidity associated with the injection of fibrin glue. CONCLUSION: In this study, fibrin glue had moderate success in the definitive treatment of perineal fistulas. However, 33 percent of the patients in whom fibrin glue was the only treatment used were able to avoid more extensive surgery. Fibrin glue is associated with minimal risk, therefore its application should be considered in patients with complex anal fistulas.