Harry Wasvary

Randomized, prospective, double-blind, placebo-controlled trial of effect of nitroglycerin ointment on pain after hemorrhoidectomy.

PURPOSE: Fissure-in-ano is characterized by pain, bleeding, and internal anal sphincter hypertonicity. Spasm of the internal sphincter also plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. Inducing sphincter relaxation with a nitroglycerin ointment has shown promise in healing anal fissures and relieving symptoms of pain. Our study attempts to test the hypothesis that topical nitroglycerin applied to the perianal region is beneficial in reducing pain after hemorrhoidectomy. METHODS: After hemorrhoidectomy 39 patients were randomly assigned to receive 0.2 percent nitroglycerin ointment (n=19) or placebo (n=20). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate to take as needed. Visual analog scales were used to measure postoperative pain intensity and ointment benefits. Patients completed questionnaires to record medication morbidity and number of prescribed or nonprescribed medications taken. RESULTS: Patients using nitroglycerin had less pain and greater benefit from ointment than those did in the placebo group, but differences were not significant. Narcotic use was higher in the placebo group when considered on a daily basis, but was statistically significant on the second postoperative day only (P<0.05). Morbidity from ointment application was significantly higher in the nitroglycerin group (P<0.002) and included a headache in 8 of 19 patients. Nonsteroidal anti-inflammatory drugs and acetaminophen were not prescribed, but were taken more frequently in nitroglycerin patients (P<0.0003). CONCLUSION: Perianal application of 0.2 percent nitroglycerin ointment after hemorrhoidectomy significantly reduced narcotic requirements on the second postoperative day. Headaches and a subsequent need for nonnarcotic medications may limit benefits of nitroglycerin.

a Randomized, Prospective, Double-blind, Placebo-controlled Trial of the Effect of a Calcium Channel Blocker Ointment on Pain After Hemorrhoidectomy

PURPOSESpasm of the internal sphincter plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. We have evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy.METHODSAfter hemorrhoidectomy, 18 patients were randomly assigned to receive 2 percent diltiazem ointment (n = 9) or a placebo ointment (n = 9). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate (Vicodin ®) to take as needed. The type and number of prescribed or nonprescribed medications taken during the postoperative period were recorded. Patients maintained a log to measure postoperative pain daily and perceived benefit of the ointment, using a Visual Analog Scale ranging from 0 to 10. Any postoperative morbidity noted during the follow-up period was recorded.RESULTSPatients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week. Postoperative pain scores in the placebo group averaged 8.8 ± 1.2 early and diminished to 5.2 ± 1.7 at the end of one week, compared to the diltiazem group of 5.2 ± 2.4 early and 2.3 ± 1.2 at the end of one week (P < 0.001, both time periods). Perceived benefit in the placebo group averaged 2.7 ± 1.2 vs. 5.6 ± 1.4 in the diltiazem group (P < 0.001). Total and daily narcotic use was higher in the placebo group, but this was not statistically significant (P = 0.13). No differences in the frequency of use of nonsteroidal anti-inflammatory drugs and acetaminophen were seen between the two groups, and there were no differences in morbidity between the two groups.CONCLUSIONSPerianal application of 2 percent diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity. Patients using a placebo ointment tend to take more prescription narcotics for pain relief postoperatively, with a similar usage of nonsteroidal anti-inflammatory drugs and acetaminophen, although differences were not significant.

Endoprosthetic management of refractory ileocolonic anastomotic strictures after resection for Crohn's disease: Report of nine-year follow-up and review of the literature

Background: The role of endoluminal stenting in benign obstruction, especially for Crohns disease (CD), is controversial, with limited data and widely disparate outcomes. The purpose of this study was to determine the long‐term efficacy and safety of this technology in the treatment of fibrostenotic CD and to review the existing literature on this topic. Methods: We undertook a retrospective review of all patients undergoing endoluminal stenting for CD strictures at our institution from 2001 to 2010. Outcome measures included technical success, clinical improvement, duration of stent and luminal patency, and need for re‐intervention. Results: Five patients underwent this procedure with a 100% rate of technical and an 80% rate of clinical success. Mean follow‐up was 28 months (range 3 weeks to 109 months) and mean long‐term luminal patency was 34.8 months (range 4.5–109 months). There was one complication involving reobstruction which required surgical intervention and no mortalities. Conclusions: Endoluminal stenting of CD strictures is a safe and effective alternative to surgery which can provide lasting benefit in select patients. Further studies are necessary to clarify the full impact of this technology on long‐term management of this complex disease. (Inflamm Bowel Dis 2012;)

Risk Factors for Anastomotic Leak and Mortality in Diabetic Patients Undergoing Colectomy: Analysis From a Statewide Surgical Quality Collaborative

OBJECTIVES To determine the risk factors in diabetic patients that are associated with increased postcolectomy mortality and anastomotic leak. DESIGN A prospectively acquired statewide database of patients who underwent colectomy was reviewed. Primary risk factors were diabetes mellitus, hyperglycemia (glucose level ≥ 140 mg/dL), steroid use, and emergency surgery. Categorical analysis, univariate logistic regression, and multivariate regression were used to evaluate the effects of these risk factors on outcomes. SETTING Participating hospitals within the Michigan Surgical Quality Collaborative. PATIENTS Database review of patients from hospitals within the Michigan Surgical Quality Collaborative. MAIN OUTCOME MEASURES Anastomotic leak and 30- day mortality rate. RESULTS Of 5123 patients, 153 (3.0%) had leaks and 153 (3.0%) died. Preoperative hyperglycemia occurred in 15.6% of patients, only 54% of whom were known to have diabetes. Multivariate analysis showed that the risk of leak for patients with and without diabetes increased only by preoperative steroid use (P<.05). Mortality among diabetic patients was associated with emergency surgery (P<.01) and anastomotic leak (P<.05); it was not associated with hyperglycemia. Mortality among nondiabetic patients was associated with hyperglycemia (P<.005). The presence of an anastomotic leak was associated with increased mortality among diabetic patients (26.3% vs 4.5%; P<.001) compared with nondiabetic patients (6.0% vs 2.5%; P<.05). CONCLUSIONS The presence of diabetes did not have an effect on the presence of an anastomotic leak, but diabetic patients who had a leak had more than a 4-fold higher mortality compared with nondiabetic patients. Preoperative steroid use led to increased rates of anastomotic leak in diabetic patients. Mortality was associated with hyperglycemia for nondiabetic patients only. Improved screening may identify high-risk patients who would benefit from perioperative intervention.

Does sedation type affect colonoscopy perforation rates

BACKGROUND: Sedation with propofol is gaining popularity. It is unclear whether sedation with propofol is associated with colonoscopic perforation. OBJECTIVE: The purpose of this study was to compare perforation rates during colonoscopy using sedation with or without propofol. DESIGN: This was a retrospective case series study. SETTINGS: Data from a tertiary center were analyzed. Demographics, method of sedation, and type of endoscopic procedure performed were collected. PATIENTS: Patients who underwent a colonoscopy from January 2003 to October 2012 were analyzed. MAIN OUTCOME MEASURES: Perforation rate expressed per 10,000 colonoscopies was measured. RESULTS: A total of 118,004 colonoscopies were performed during the study period, with 48 perforations (0.041% or 4.1 per 10,000). Overall, the use of propofol was associated with a 2.5 times increased rate of perforation (6.9 vs 2.7 per 10,000; p = 0.0015). Similarly, in patients undergoing therapeutic colonoscopies, there was a 3.4-times increased risk of perforation associated with the use of propofol (8.7 vs 2.6 per 10,000; p = 0.0016). However, in patients undergoing diagnostic colonoscopies, there was no significantly increased risk of perforation with the use of propofol (4.2 vs 2.9 per 10,000; p = 0.64). In univariate and multivariate analyses, there were no differential perforation risks on the basis of sex, but each decade increase in age was associated with an increased risk of perforation. In those patients having a therapeutic colonoscopy, age (per decade) and propofol use were independently and significantly associated with an increased perforation risk, with adjusted ORs of 1.32 (p = 0.04) and 3.38 (p = 0.001). LIMITATIONS: This was a retrospective study with the potential for selection bias. CONCLUSIONS: This study shows that propofol administration is associated with an increased risk of colonoscopic perforation among patients undergoing a therapeutic colonoscopy; however, this association was not evident in patients undergoing a diagnostic colonoscopy. Further studies, such as a prospective, randomized clinical trial, should be done to further evaluate this association.

Predictive factors affecting survival in stage II colorectal cancer: is lymph node harvesting relevant?

PURPOSE: Lymph node status is important in colorectal cancer. Multiple studies indicate a relationship between the number of nodes harvested and survival. This is important in patients with stage II disease where the role of adjuvant therapy is unclear. This study sought to analyze the impact of lymph node harvest on survival in patients with stage II colorectal cancer. METHODS: The data of our hospitals colorectal tumor registry from 1997 to 2008 was reviewed. The records of 3534 patients of all stages were analyzed; of these patients, 913 patients with stage II colorectal cancer underwent curative resection. A univariate analysis estimated 5-year survival by Kaplan-Meier analysis based on various lymph node groupings. Patients were further analyzed with respect to sex, age, tumor grade, and tumor location. Multivariate linear regression analysis by the Cox proportional hazards model was performed using these variables to analyze survival relative to lymph node harvesting. RESULTS: Of 913 stage II patients, the mean age was 71 years and 48% were male. Univariate analysis of the number of lymph nodes harvested found that ≥24 nodes removed was a significant and independent factor for improved survival in stage II (P = .009) and ≥36 nodes in stage III cancers (P = .008). Cox proportional hazards ratios found male sex (P < .03) and poorly differentiated tumors (P < .015) to be negative independent risk factors for survival. Tumor location in the sigmoid was associated with improved survival (P < .02). CONCLUSION: Patients with stage II disease had an improved survival when ≥24 lymph nodes were harvested, and patients with stage III disease had improved survival with up to a 36 node harvest. Male sex and poorly differentiated tumors had a worse prognosis, and tumors located in the sigmoid were associated with improved survival in stage II cancers. An increased lymph node harvest is recommended to improve survival in these stages.

Evaluating the age distribution of patients with colorectal cancer: are the United States Preventative Services Task Force guidelines for colorectal cancer screening appropriate?

PURPOSE: Evaluate the appropriateness of the 2008 United States Preventative Services Task Force screening recommendations for colorectal cancer. METHODS: Ages at diagnosis data were collected on patients with colorectal cancer from the William Beaumont Tumor Registry. The database identified 6,925 patients treated for colorectal cancer between January 1973 and December 2007. Patients were divided into 3 age groups at diagnosis categories (younger than 50 years old, those 50 to 75 years old, and those older than 75 years old) to evaluate whether there were changes in the age distribution, pathologic stage, or tumor location during the 35-year period. RESULTS: The percent of patients with colorectal cancer older than age 75 years increased from 29% to 40% (P < .0001). The combined percentage of patients younger than age 50 years and older than age 75 years has increased from 36% (1973–1978) to 49% (2003–2007). The combined percentages of stage III and IV disease in patients younger than 50 years and older than 75 years were 51% and 34%, respectively (P < .0001). Rectal or left-sided lesions occurred in 68%, 64%, and 50% of patients younger than 50 years old, those 50 to 75 years old, and those older than 75 years old, respectively (P < .0001). Right-sided lesions occurred in 22%, 25%, and 37% of those younger than 50 years old, those 50 to 75 years old, and those older than 75 years old, respectively (P < .0001). CONCLUSIONS: There has been a significant increase in the percentage of colorectal cancer patients older than age 75 years. Failing to screen patients younger than 50 years and older than the age of 75 years would miss 49% of patients treated at our institution from 2003 to 2007.

Minimally invasive, endoscopically assisted colostomy can be performed without general anesthesia or laparotomy.

AbstractPURPOSE: Fecal diversion is frequently required in critically ill patients who may not be able to tolerate a laparotomy. Laparoscopic-assisted and trephine colostomies are alternative methods for colostomy without laparotomy, but require general anesthetic. The objective of this study was to evaluate the possibility of performing fecal diversion with the assistance of a colonoscope and without the additional morbidity of abdominal exploration or general anesthesia. METHODS: Patients were diverted using a colonoscope to identify a site of the sigmoid colon that could easily be approximated to the anterior abdominal wall as confirmed by transillumination of the abdominal wall. A small skin disc was then removed at this location and a loop colostomy was made. The colonoscope was also used as a guide to identify the proximal and distal limbs of the loop colostomy. Four patients were considered to be critically ill and local or regional anesthetic with sedation was used in these patients. RESULTS: A total of 15 patients were reviewed during the past five years. All 15 patients were successfully diverted using minimally invasive techniques with the aid of the colonoscope. Four of these patients were diverted using local or regional anesthetic without complication, thus avoiding the morbidity associated with a general anesthetic in critically ill patients. CONCLUSION: No complications related to this technique were noted in this five-year review. Endoscopically assisted colostomy is an acceptable method for fecal diversion without the need for laparotomy and can be accomplished using a local or regional anesthetic with sedation.

Implementing a Multidisciplinary Open-Access Clinic at a Private Practice–Based Community Hospital

With the acquisition of emerging technologies in the treatment of primary and metastatic hepatic malignancy by interventional radiology, a multidisciplinary tumor board was created by the authors to improve treatment planning for these diseases.

Retrorectal teratoma: a rare cause of pain in the tailbone.

Retrorectal tumors are extremely rare and heterogeneous, requiring complete surgical excision for definitive diagnosis and optimal outcome. We describe a patient presenting with chronic “tailbone pain” who was found to have a benign cystic teratoma in the presacral space. She underwent en bloc resection and recovered well. Radiographic and pathologic images from this unique case are depicted and clinical features discussed.