Janice F. Rafferty

Practice parameters for the treatment of sigmoid diverticulitis.

Diseases of the Colon & ReCtum Volume 57: 3 (2014) the american society of Colon and Rectal surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. the Clinical Practice Guideline Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. this Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. this is accompanied by developing Clinical Practice Guidelines based on the best available evidence. these guidelines are inclusive, and not prescriptive. their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. these guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. it should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Practice parameters for the management of colon cancer.

DISEASES OF THE COLON & RECTUM VOLUME 55: 8 (2012) The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which to base decisions, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures

AbstractPURPOSE: The aim of this study was to determine the optimal dose and dosing interval of nitroglycerin ointment to heal chronic anal fissures. METHOD: A randomized, double-blind study of intra-anally applied nitroglycerin ointment (Anogesic™) was conducted in 17 centers in 304 patients with chronic anal fissures. The patients were randomly assigned to one of eight treatment regimens (0.0, 0.1, 0.2, 0.4 percent nitroglycerin ointment applied twice or three times per day), for up to eight weeks. A dose-measuring device standardized the delivery of 374 mg ointment. Healing of fissures (complete reepithelialization) was assessed by physical examination using an observer unaware of treatment allocation. The subjects assessed pain intensity daily by completing a diary containing a visual analog scale for average pain intensity for the day, the worst pain intensity for the day, and pain intensity at the last defecation. RESULTS: There were no significant differences in fissure healing among any of the treatment groups; all groups, including placebo had a healing rate of approximately 50 percent. This rate of placebo response was inexplicably higher than previously reported in the literature. Treatment with 0.4 percent (1.5 mg) nitroglycerin ointment was associated with a significant (P < 0.0002) decrease in average pain intensity compared with vehicle as assessed by patients with a visual analog scale. The decreases were observed by Day 4 of treatment. At 8 weeks the magnitude of the difference between 0.4 percent nitroglycerin and control was a 21 percent reduction in average pain. Treatment was well tolerated, with only 3.29 percent of patients discontinuing treatment because of headache. Headaches were the primary adverse event and were dose related. CONCLUSION: Nitroglycerin ointment did not alter healing but significantly and rapidly reduced the pain associated with chronic anal fissures.

Practice Parameters for the Management of Anal Fissures (3rd Revision)

T he American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Practice guideline for the surveillance of patients after curative treatment of colon and rectal cancer

Current evidence suggests improved rates of curative secondary treatment following identification of recurrence among patients who participate in a surveillance program after initial curative resection of colon or rectal cancer. The newer data show that surveillance CEA, chest and liver imaging,and colonoscopy can also improve survival through early diagnosis of recurrence; thus, these modalities are now included in the current guideline. Although the optimum strategy of surveillance for office visits, CEA, chest and liver imaging, and colonoscopy is not yet defined, routine surveillance does improve the detection of recurrence that can be resected with curative intent. Recommended surveillance schedules are shown in Table 4. However, the factors to be considered when recommending surveillance include underlying risk for recurrence, patient comorbidity, and the ability to tolerate major surgery to resect recurrent disease or palliative chemotherapy, performance status, physiologic age, preference, and compliance. The success of surveillance for early detection of curable recurrence will depend on patient and provider involvement to adhere to the surveillance schedule and avoid unnecessary examination. It should be noted that, after curative resection of colorectal cancer, patients are still at risk for other common malignancies(lung, breast, cervix, prostate) for which standard screening recommendations should be observed and measures to maintain general health (risk reduction for cardiovascular disease, eg, cessation of smoking, control of blood pressure and diabetes mellitus, balanced diet, regular exercise and sleep, and flu vaccines) should be recommended.

Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse

Purpose: This study was undertaken to document the effect of pudendal nerve function on anal incontinence after repair of rectal prolapse. METHODS: Patients with full rectal prolapse (n=24) were prospectively evaluated by anal manometry and pudendal nerve terminal motor latency (PNTML) before and after surgical correction of rectal prolapse (low anterior resection (LAR; n=13) and retrorectal sacral fixation (RSF; n=11)). RESULTS: Prolapse was corrected in all patients; there were no recurrences during a mean 25-month follow-up. Postoperative PNTML was prolonged bilaterally (>2.2 ms) in six patients (3 LAR; 3 RSF); five patients were incontinent (83 percent). PNTML was prolonged unilaterally in eight patients (4 LAR; 4 RSF); three patients were incontinent (38 percent). PNTML was normal in five patients (3 LAR; 2 RSF); one was incontinent (20 percent). Postoperative squeeze pressures were significantly higher for patients with normal PNTML than for those with bilateral abnormal PNTML (145vs.66.5 mmHg;P=0.0151). Patients with unilateral abnormal PNTML had higher postoperative squeeze pressures than those with bilateral abnormal PNTML, but the difference was not significant (94.8vs.66.5 mmHg; P=0.3182). The surgical procedure did not affect postoperative sphincter function or PNTML. CONCLUSION: Injury to the pudendal nerve contributes to postoperative incontinence after repair of rectal prolapse. Status of anal continence after surgical correction of rectal prolapse can be predicted by postoperative measurement of PNTML.

Readmission for dehydration or renal failure after ileostomy creation.

BACKGROUND: Ileostomy creation is a commonly performed operation in colorectal surgery; however, many patients develop complications such as dehydration postoperatively. Dehydration is often severe enough to warrant hospital readmission and may result in renal failure. The true incidence of this complication has not been well described. OBJECTIVE: The aim of this study was to identify the rate of hospital readmission secondary to dehydration or renal failure within 30 days of ileostomy creation. DESIGN: Retrospective review of all patients undergoing ileostomy creation from 2007 to 2011 in a single colorectal practice of 4 surgeons was performed. Charts were reviewed to identify patients readmitted for dehydration or renal failure within 30 days of operation. Data were then analyzed to identify predictors of readmission, dehydration, and renal failure. Subset analysis compared patients readmitted with simple dehydration versus patients with renal failure. PATIENTS: Two hundred one patients undergoing colorectal operations that included ileostomy creation within a 4-year period at a single institution for a variety of indications were included. MAIN OUTCOME MEASURES: The primary outcome measured was readmission for dehydration or renal failure. RESULTS: We observed a 17% 30-day readmission rate for dehydration or renal failure following ileostomy creation. Age greater than 50 was identified as an independent predictor of readmission with renal failure, whereas IPAA was predictive of readmission for simple dehydration, but not renal failure. Patients admitted with renal failure had significantly longer hospital stays and median hospital charges after readmission in comparison with patients admitted with simple dehydration. LIMITATIONS: This study was limited by its retrospective nature and its limited sample size. CONCLUSION: Hospital readmission due to dehydration or renal failure following ileostomy creation is common, with age >50 being the strongest predictor for renal failure. Appropriate strategies to decrease dehydration and renal failure following ileostomy creation need to be investigated.

The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence.

623 Diseases of the Colon & ReCtum Volume 58: 7 (2015) the american society of Colon and Rectal surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. the Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. this Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. this is accompanied by developing Clinical Practice Guidelines based on the best available evidence. these guidelines are inclusive and not prescriptive. their purpose is to provide information based on which decisions can be made, rather than to dictate a specific form of treatment. these guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. it should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Sepsis in rats stimulates cellular proliferation in the mucosa of the small intestine

BACKGROUND/AIMS Increased protein synthesis in intestinal mucosa during sepsis may reflect increased cell turnover. The influence of sepsis and endotoxemia on cellular proliferation in the mucosa of the small intestine was studied. METHODS Sepsis was induced in rats by cecal ligation and puncture. Control rats were sham-operated. Other rats were treated with endotoxin (total dose, 2 mg/kg), human recombinant tumor necrosis factor alpha, or human recombinant interleukin 1 alpha at a dose of 100 micrograms/kg each. Villus height and crypt depth in the jejunum were measured as the number of cells along the side of the villus and crypt, respectively. Cellular proliferation was assessed by measuring the rate of [3H]thymidine incorporation into DNA of the jejunal mucosa and performing autoradiographic studies after intravenous administration of [3H]thymidine. RESULTS Sepsis resulted in reduced villus height, increased crypt depth, and increased incorporation of [3H]thymidine into DNA in the jejunal mucosa. Autoradiography after administration of [3H]thymidine showed labeled cells almost exclusively in the crypts; the number of labeled cells per crpt was higher in septic than in control rats. Administration of endotoxin or recombinant interleukin 1 alpha, but not recombinant tumor necrosis factor alpha, stimulated the incorporation of [3H]-thymidine into DNA in the jejunal mucosa. CONCLUSION Sepsis and endotoxemia stimulate cellular proliferation in the mucosa of the small intestine. This response to sepsis and endotoxemia may be partly mediated by interleukin 1.

Practice parameters for the management of rectal prolapse.

T he American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.