Jae Sik Joo

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch

AIM: This study was designed to analyze the functional and clinical outcomes of straight coloanal anastomosis compared with colonic J-pouch performed after low anterior resection. MATERIALS AND METHODS: Between September 1989 and June 1996, all patients who underwent low anterior resection with anastomosis less than 4 cm from the dentate line were classified into two groups based on the restoration of intestinal continuity: “straight” coloanal anastomosis (n=39) or colonic J-pouch (n=44). Both groups were assessed according to the level of anastomosis, anastomotic complications (stricture, leak, pelvic abscess), age, and gender. For comparison of functional outcome, daily bowel movements, tenesmus, urgency, incontinence score (range, 0–20), and anorectal manometric findings were evaluated preoperatively and at six months, and one and two years after surgery. RESULTS: There were no significant differences between the groups relative to age: (coloanal anastomosis, 66.3±10.1 (range, 46–86),vs. colonic J-pouch, 64.9±13.2 (range, 39–88) years); gender (females): (coloanal anastomosis, 46.2 percentvs. colonic J-pouch; 38.6 percent); diagnosis: (rectal carcinoma: coloanal anastomosis, 84.6 percent,vs. colonic J-pouch, 77.3 percent); preoperative incontinence score (coloanal anastomosis, 1.5±4.6,vs. colonic J-pouch, 1.1±4); bowel movements: (coloanal anastomosis, 2.1±2.3,vs. colonic J-pouch, 2.1±1.9/day); level of anastomosis: (coloanal anastomosis, 1.8±1.3,vs. colonic J-pouch, 1.5±1.3 cm from the dentate line); history of perioperative radiation therapy: (coloanal anastomosis, 15.4 percent,vs. colonic J-pouch, 20.5 percent); or manometric findings. There was also no significant difference in postoperative mortality: (coloanal anastomosis, 5.1 percent,vs. colonic J-pouch, 2.3 percent); or anastomotic complications: (coloanal anastomosis, 7/39 (17.9 percent),vs. colonic J-pouch, 2/44 (4.5 percent)P=0.08); strictures: (10.3vs. 0 percent); leaks: (5.1vs. 2.3 percent); bleeding: (2.6vs. 0 percent); rectovaginal fistula: (0vs. 2.3 percent). Also, in the colonic J-pouch group, two patients developed pouchitis, and one patient experienced difficult evacuation one year after surgery. There was a statistically significant better function judged by less frequent bowel movements (4±2vs. 2.4±1.3/day;P<0.005) and urgency (36.7vs. 7.7 percent;P<0.05), incontinence score (2.2±3.7vs. 0.8±1.6;P<0.05) up to one year after surgery. At two years, the coloanal anastomosis group did not show statistical improvement in functional results compared with one year postoperatively. Rectal compliance in manometric findings was significantly increased in the coloanal anastomosis group at one year after surgery (12.4±12.6vs. 4.2±1.5 ml/mmHg;P<0.05). However, these differences were less profound after two years. CONCLUSION: The functional superiority of the colonic J-pouch was greatest at one year after surgery. By two years, adaptation of the “straight” coloanal anastomosis yielded similar functional results. However, the almost fourfold reduction in anastomotic complications in the colonic J-pouch group reveals a second potential advantage of this technique.

Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy

AbstractBackground: The aim of this study was to evaluate disability after laparoscopic colectomy in patients with benign colorectal disease. Methods: Patients who underwent laparoscopic colectomy for benign colorectal diseases were matched with patients who underwent laparotomy for the same diseases by the same surgeons during the same time period. A standardized questionnaire used to assess disability included days until return to partial activity, full activity, and work. Results: Seventy-one patients who underwent laparotomy were compared with 71 patients who underwent laparoscopy. Pathology included 26 patients with adenoma, 23 with Crohns disease, 13 with diverticulitis, and 9 with reversal of Hartmanns procedure in each group. Procedures were partial colectomy with ileocolostomy, colocolostomy, or colorectostomy. There were no significant differences (p > 0.05) in age (55.8 vs. 59.7 years) or in the incidence of perioperative complications (25% vs. 29%) between the laparoscopy and laparotomy groups, respectively. The operative time was longer in the laparoscopic group than in the laparotomy group: 165 versus 122 min (p < 0.001). However, length of hospitalization, return to partial and full activity, and time off of work were significantly shorter in the laparoscopy than in the laparotomy group: 6.3 versus 9.0 days, 2.1 versus 4.4 weeks, 4.2 versus 10.5 weeks and 3.8 versus 7.5 weeks, respectively (p < 0.01 for all). Conclusions: Laparoscopic colectomy for benign colorectal diseases was associated with significantly less disability than was laparotomy in terms of length of hospitalization as well as return to baseline partial and full activity and employment.

Initial North American experience with botulinum toxin type a for treatment of anismus

PURPOSE: Botulinum toxin type A (BTX-A), produced byClostridium botulinum,is a potent neurotoxin. The purpose of this study was to evaluate the efficacy of BTX-A for treatment of anismus. MATERIALS AND METHODS: All patients treated with BTX-A for anismus were evaluated. Eligibility criteria included a history of chronic assisted evacuation (laxatives, enemas, or suppositories), demonstration of anismus by cinedefecogram and electromyography, and failure of a minimum of three sessions of supervised biofeedback therapy (BF). Contingent on body mass, 6 to 15 units of BTX-A was injected bilaterally under electromyography guidance into the external sphincter or the puborectalis muscle. Treatment was repeated as necessary for a maximum of three sessions during a three-month period. Success was considered as discontinuation of evacuatory assistance and was evaluated between one and three months and again at up to one year. RESULTS: Between July 1994 and May 1995, four patients ranging from 29 to 82 years in age (2 females, 2 males) had anismus that failed to respond to between 3 and 15 biofeedback sessions. All patients improved between one and three months after BTX-A injection, and two had sustained improvement for a range of three months to one year. There was no morbidity or mortality associated with BTX-A injection. CONCLUSIONS: BTX-A is extremely successful for temporary treatment of anismus that is refractory to BF management. However, because the mechanism of action is short, longer term results are only 50 percent successful. Hopefully, modifications in the strain of BTX-A and dose administered will allow longer periods of success or a repeat trial of BF. Nonetheless, this preliminary report is very encouraging in offering a method of managing this recalcitrant condition.

Laparoscopic colorectal surgery : Do we get faster ?

AbstractBackground: A variety of parameters can affect the outcome of laparoscopic colorectal surgery. All consecutive laparoscopic colorectal procedures (LCP) were analyzed in an attempt to define an operative time curve for different categories of procedures. Additionally, impacts of case number and procedure type on length of procedure were assessed. Methods: Our computerized data system was reviewed for all patients who underwent LCP in a 4-year period. Parameters reviewed included age, sex, surgical indications, procedures performed, length of procedure, intraoperative and postoperative complications, incidence and causes for conversion, duration of postoperative ileus, and hospital stay. Results: Between August 1991 and December 1995, 175 patients with a mean age of 48.4 (range 15–88) years underwent LCP. Patients were divided chronologically into five consecutive groups. Procedures were classified as either basic or complex. Complex procedures were those in which there was either a fixed tumor, an abscess or fistula, or extensive intraabdominal adhesions from prior surgery. Complex procedures performed each year ranged from 37% to 66%. As well, the percentage of patients with adhesions increased from 17% in 1991 to 29% in 1995. Despite increased difficulty, the intraoperative complication rate fell significantly from 29% in 1991 to 8% in 1995 (p < 0.005). Additionally, the operative length decreased from a mean of 201 min in 1991 to a mean of 141 min in 1995 (p < 0.05). Conclusion: The rapid improvement in these parameters may reflect both ascents in the learning curve and change in type of procedure. Adhesions, due to prior surgery or inflammation making dissection tedious, is the most important technical factor which effects operation time (p < 0.001). However, despite increased complexity, operating time decreased, reflecting improved skills. Thus, the experienced laparoscopic surgeon can increase the spectrum of applications with expectations of shorter operations and lower complication rates.

Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited.

Cathartic colon is a historic term for the anatomic alteration of the colon secondary to chronic stimulant laxative use. Because some have questioned whether this is a real entity, we investigated changes occurring on barium enema in patients ingesting stimulant laxatives. Our study consisted of two parts. In part 1, a retrospective review of consecutive barium enemas performed on two groups of patients with chronic constipation (group 1, stimulant laxative use [n=29]; group 2, no stimulant laxative use [n=26]) was presented to a radiologist who was blinded to the patient group. A data sheet containing classic descriptions of cathartic colon was completed for each study. Chronic stimulant laxative use was defined as stimulant laxative ingestion more than three times per week for 1 year or longer. To confirm the findings of the retrospective study, 18 consecutive patients who were chronic stimulant laxative users underwent barium enema examination, and data sheets for cathartic colon were completed by another radiologist (part 2). Colonic redundancy (group 1, 34.5%; group 2, 19.2%) and dilatation (group 1, 44.8%; group 2, 23.1%) were frequent radiographic findings in both patient groups and were not significantly different in the two groups. Loss of haustral folds, however, was a common finding in group 1 (27.6%) but was not seen in group 2 (p < 0.005). Loss of haustral markings occurred in 15 (40.5%) of the total stimulant laxative users in the two parts of the study and was seen in the left colon of 6 (40%) patients, in the right colon of 2 (13.3%) patients, in the transverse colon of 5 (33.3%) patients, and in the entire colon of 2 (13.3%) patients. Loss of haustra was seen in patients chronically ingesting bisacodyl, phenolpthalein, senna, and casanthranol. We conclude that long-term stimulant laxative use results in anatomic changes in the colon characterized by loss of haustral folds, a finding that suggests neuronal injury or damage to colonic longitudinal musculature caused by these agents.

Intraoperative laparoscopic complications

PURPOSE: The aim of this study was to assess various intraoperative and postoperative complications associated with laparoscopic colorectal surgery. Specifically, the impact of surgical experience and procedure type on complications was analyzed. METHODS: All patients who underwent laparoscopic surgery were analyzed by age, sex, surgical indications, procedure performed, procedure length, intraoperative and postoperative complications, incidence and causes for conversion, duration of postoperative ileus, and length of hospital stay. Patients were classified for type of procedure and chronologically into four consecutive groups. Procedures were also categorized into four different groups: GI, total abdominal colectomies; GII, segmental resections; GIII, diverting procedures; GIV, others (abdominoperineal resection, Hartmanns creation or closure, anterior resection, and rectopexy). RESULTS: Between August 1991 and October 1995, 167 patients of a mean age of 49.6 (15–88) years underwent laparoscopic colorectal procedures. All procedures were electively performed. Common indications for surgery included inflammatory disease in 70 (42 percent), neoplasia in 56 (33 percent), functional bowel disorders in 30 (18 percent), and other forms of colorectal disorders in 11 (7 percent) patients. The most significant variable affecting intraoperative laparoscopic complication rate was surgical experience measured as the time interval during which surgery was performed (P=0.02). Total complication rate decreased from 29 percent during the first period to 11 percent by the second period (P<0.04) and 7 percent during the third period (P<0.005). Thus, the learning curve appeared to have required more than 50 cases to achieve. Moreover, even after performance of 94 (1991–1993) procedures in GI and GIV, these procedures were associated with higher complication rates than were those procedures in GII and GIII (P=0.04). CONCLUSION: Surgical experience and case selection are the most critical variables by which the surgeon can decrease the intraoperative laparoscopic complication rate.

Is laparoscopic resection of colorectal polyps beneficial

AbstractBackground: We set out to compare the results of laparoscopic and open resections of colorectal polyps. Methods: Forty-five consecutive patients who underwent operation by a single surgeon for endoscopically irretrievable colonic polyps between April 1992 and March 1996 were classified into the following two groups: group I, laparoscopic procedures for colonic polyps (n= 23); and group II, open procedures for colonic polyps (n= 22). Results: No significant differences were seen between the groups relative to age [71.7 ± 10.7 versus 70.6 ± 13.7 years], gender [male:female = 10:13 versus 13:9], history of previous abdominal operation (eight of 23 [34.8%] versus 10 of 22 [45.5%]), type of pathology (villous: seven of 23 [30.4%] versus four of 22 [18.1%], tubulovillous: nine of 23 [39.1%] versus six of 22 [27.2%], tubular: three of 23 [13.0%] versus seven of 22 [31.8%]), size of polyps (2.6 ± 1.7 cm versus 2.7 ± 1.5 cm), or type of procedures (right hemicolectomy: 15 of 23 [65.2%] versus 11 of 22 [50%], sigmoid colectomy: five of 23 [21.7%] versus six of 22 [27.3%], left hemicolectomy: two of 23 [8.7%] versus two of 22 [9.1%]). There was no mortality and no difference in the incidence of postoperative complications (four of 23 [17.4%] versus seven of 22 [31.8%]), blood loss (167 cc versus 243 cc), number of retrieved lymph nodes (7.1 ± 5 versus 6.6 ± 4), incidence of carcinoma in polyps (two of 23 [13.0%] versus four of 22 [18.2%]), or medical cost (

Recurrent rectal prolapse

22,840 versus

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch is the functional superiority of colonic J-pouch sustained?

18,420), respectively, between the two groups. There were statistically significant differences in length of ileus (3.5 ± 1.0 days versus 5.5 ± 1.8 days), postoperative pain (2.3 ± 1.4 versus 3.7 ± 1.9 on postoperative day 1 [patient pain rating scale 1–10]), length of hospital stay (6.5 ± 2.0 days versus 9.4 ± 2.7 days), and return to normal activity (5.2 ± 4.2 weeks versus 9.3 ± 12.1 weeks) in group I compared to group II, respectively. However, patients in group II had a longer mean specimen length (18.5 ± 6.4 cm versus 29.1 ± 22.7 cm) and a shorter mean operative time (177.6 ± 52.7 min versus 143 ± 51.4 min) than patients in group I. Conclusions: Laparoscopic colectomy for colonic polyps has definite advantages over traditional open surgery, including less postoperative pain, earlier return of bowel function, and earlier return to normal activity. Conversely, its disadvantages include longer operative time and a shorter specimen.

Endorectal advancement flap in perianal Crohn's disease.

PURPOSE: The aim of this study was to assess the clinical and functional outcome of surgery for recurrent rectal prolapse and compare it with the outcome of patients who underwent primary operation for rectal prolapse. METHODS: All patients who underwent surgery for rectal prolapse were evaluated for age, gender, procedure, anorectal manometry and electromyography findings, and morbidity. The results for patients who underwent surgery for recurrent rectal prolapse were compared with a group of patients matched for age, gender, surgeon, and procedure who underwent primary operations for rectal prolapse. RESULTS: A total of 115 patients underwent surgery for rectal prolapse. Twenty-seven patients, 10 initially operated on at this institution and 17 operated on elsewhere, underwent surgery for recurrent rectal prolapse. These 27 patients were compared with 27 patients with primary rectal prolapse operated on in our department. In the recurrent rectal prolapse group, prior surgery included rectopexy in 7 patients, Delormes procedure in 7 patients, perineal rectosigmoidectomy in 7 patients, anal encirclement procedure in 4 patients, and resection rectopexy in 2 patients. Operations performed for recurrence were perineal rectosigmoidectomy in 14 patients, resection rectopexy in 8 patients, rectopexy in 2 patients, pelvic floor repair in 2 patients, and Delormes procedure in 1 patient. There were no statistically significant differences between the groups in preoperative incontinence score (recurrent rectal prolapse, 13.6±7.8vs. rectal prolapse, 12.7±7.2; range, 0–20) or manometric or electromyography findings, and there were no significant differences in mortality (0vs. 3.7 percent), mean hospital stay (5.4±2.5vs. 6.9±2.8 days), anastomotic complications (anastomotic stricture (0vs. 7.4 percent), anastomotic leak (3.7vs. 3.7 percent) and wound infection (3.7vs. 0 percent)), postoperative incontinence score (2.8±4.8vs. 1.5±2.7), or recurrence rate (14.8vs. 11.1 percent) between the two groups at a mean follow-up of 23.9 (range, 6–68) and 22 (range, 5–55) months, respectively. The overall success rate for recurrent rectal prolapse was 85.2 percent. CONCLUSION: The outcome of surgery for rectal prolapse is similar in cases of primary or recurrent prolapse. The same surgical options are valid in both scenarios.