Jeff Hammel

Prospective, Age-Related Analysis of Surgical Results, Functional Outcome, and Quality of Life After Ileal Pouch-Anal Anastomosis

Objective To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA). Summary Background Data Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age. Methods IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46–55 (n = 289), 56–65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery. Results Patients were followed for 4.6 ± 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant. Conclusions These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.

Introduction:Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer. Aim:To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer. Methods:A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed. Results:Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 ±12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups. Conclusions:In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

The Outcome After Restorative Proctocolectomy With or Without Defunctioning Ileostomy

PurposeControversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy.MethodsData regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of lifeindicators were prospectively recorded and compared.ResultsPatients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes.ConclusionsFor carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase inseptic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score.

Background/Objective:Postoperative ileus (POI) after colorectal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra-, and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic partial colectomy. Methods:Patients operated between 2004 and 2008 were retrospectively identified from a prospectively maintained database, and clinical, metabolic, and pharmacologic data were obtained. Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Associations between likelihood of POI and study variables were assessed univariably by using &khgr;2 tests, Fisher exact tests, and logistic regression models. A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors. Results:A total of 413 patients (mean age, 58 years; 53.5% women) were included, and 42 (10.2%) of them developed POI. Preoperative albumin, postoperative deep-vein thrombosis, and electrolyte levels were associated with POI. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis, which allowed the creation of a predictive score. Patients with a score of 2 or higher had an 18.3% risk of POI (P < 0.001). Conclusion:Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors. The likelihood of POI can be predicted by using a preoperative scoring system. Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients.

Frequency and Impact of Pulmonary Hypertension in Patients With Obstructive Sleep Apnea Syndrome

The correlates and consequences of pulmonary hypertension (PH) associated with obstructive sleep apnea (OSA) are poorly understood. Patients undergoing pulmonary artery catheterization within 6 months of an overnight polysomnography showing OSA were included in the present analysis. A total of 83 patients with complete data were analyzed (no PH, n = 25 [30%]; PH, 58 [70%]; of these, 18 had a pulmonary capillary wedge pressure of <15 mm Hg). No significant differences were observed between the PH and no PH groups regarding age or apnea-hypopnea index. The correlates of PH were elevated right ventricular systolic pressure (p <0.001), body mass index (p = 0.026), female gender (p = 0.01), nocturnal desaturation (82% vs 18%), and forced vital capacity <70% (p = 0.04) on univariate analysis and female gender (p = 0.03), age <49 years (p = 0.02), body mass index of > or =26 kg/m(2) (p = 0.08), and right ventricular systolic pressure of > or =30 mm Hg (p <0.001) on multivariate analysis. Patients with PH had a lower 6-minute walk distance (285.5 +/- 122 m vs 343 +/- 213 m, p = 0.4). The survival rate at 1, 4, and 8 years for patients with PH was 93%, 75%, and 43% compared to 100%, 90%, and 76% for patients without PH, respectively. Patients with severe PH (n = 27; 33%) had more nocturnal desaturation (p = 0.045), worse pulmonary hemodynamics, and greater mortality (37%) than the groups with mild or moderate PH (16%) or no PH (16%). In conclusion, our results have shown that, although generally mild to moderate, severe PH can occur in patients with OSA. Female gender, younger age, obesity, and nocturnal desaturation were associated with PH. PH can cause functional limitations and increased mortality in patients with OSA.

Divergent Oncogenic Changes Influence Survival Differences between Colon and Rectal Adenocarcinomas

PURPOSE: Colorectal cancers develop through various mechanisms such as chromosomal instability, DNA mismatch repair deficiency (microsatellite instability), and epigenetic DNA promoter methylation (CpG island methylator phenotype). This study evaluated the disparity in neoplastic changes between colon and rectal cancers. METHODS: A clinic-based colorectal frozen tumor bank at a single institution was queried for colon and rectal adenocarcinomas. Tumor DNA was extracted and analyzed for microsatellite instability, methylation, and mutations in the oncogenes KRAS and BRAF. Patient demographics, tumor characteristics, and clinical outcomes were compared. RESULTS: The 268 patients with colon cancer and 89 with rectal cancer were similar in gender, tumor size, stage, and differentiation. Colon cancers had a higher incidence of microsatellite instability (27 percent) and methylator phenotype (28 percent) compared with rectal cancers (7 percent, 3 percent, respectively; P < 0.001). Although KRAS mutation rate was similar, colon cancers had a higher incidence of BRAF mutations (16.7 percent vs. 0 percent; P < 0.001). Microsatellite stable tumors had an increased risk of disease recurrence compared with microsatellite unstable tumors (odds ratio, 3.86). Despite overall differences in outcome between colon and rectal cancers, no significant difference in survival existed when similar molecular phenotypes were compared across anatomic sites. CONCLUSIONS: Although colon cancers are molecularly heterogeneous, rectal cancers arise mostly via a single neoplastic pathway. Genetic and molecular differences influence prognosis more than anatomic location and suggest that oncogenic pathways contribute to survival differences between colon and rectal cancers.

The clinical significance of an elevated postoperative glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control?

Objectives: To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery. Methods: Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center. Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and/or based on HbA1C levels. The association between any elevated postoperative random glucose value (hyperglycemia: >125 mg/dL) and level of elevation (>125 mg/dL or >200 mg/dL) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed. Results: Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7% patients experienced hyperglycemia. Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity (blood loss). Hyperglycemia was associated with infectious and noninfectious complications and mortality, the rates of these complications increasing parallel to the degree of hyperglycemia. Hyperglycemia was independently associated with septic complications (P = 0.024). Conclusions: Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients. Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality; this risk is related to the degree of glucose elevation. These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients.

The effect of colorectal surgery in female sexual function, body image, self-esteem and general health: a prospective study.

Objective:To evaluate womens sexual function, self-esteem, body image, and health-related quality of life after colorectal surgery. Summary Background Data:Current literature lacks prospective studies that evaluate female sexuality/quality of life after colorectal surgery using validated instruments. Methods:Sexual function, self-esteem, body image, and general health of female patients undergoing colorectal surgery were evaluated preoperatively, at 6 and 12 months after surgery, using the Female Sexual Function Index, Rosenberg Self-Esteem scale, Body Image scale and SF-36, respectively. Results:Ninety-three women with a mean age of 43.0 +/− 11.6 years old were enrolled in the study. Fifty-seven (61.3%) patients underwent pelvic and 36 (38.7%) underwent abdominal procedures. There was a significant deterioration in overall sexual function at 6 months after surgery, with a partial recovery at 12 months (P = 0.02). Self-esteem did not change significantly after surgery. Body image improved, with slight changes at 6 months and significant improvement at 12 months, compared with baseline (P = 0.05). Similarly, mental status improved over time with significant improvement at 12 months, with values superior than baseline (P = 0.007). Physical recovery was significantly better than baseline in the first 6 months after surgery with no significant further improvement between 6 and 12 months. Overall, there were no differences between patients who had abdominal procedures and those who underwent pelvic dissection, except that patients from the former group had faster physical recovery than patients in the latter (P = 0.031). When asked about the importance of discussing sexual issues, 81.4% of the woman stated it to be extremely or somewhat important. Conclusion:Surgical treatment of colorectal diseases leads to improvement in global quality of life. There is, however, a significant decline in sexual function postoperatively. Preoperative counseling is desired by most of the patients.

Individual surgeon, pathologist, and other factors affecting lymph node harvest in stage II colon carcinoma. is a minimum of 12 examined lymph nodes sufficient?

BackgroundInsufficient lymph node harvest in presumed stage II colon carcinomas can result in understaging and worsened cancer outcomes. The purpose of this study was to evaluate factors affecting the number of lymph node examined, their corresponding impact on cancer outcomes, and the optimal number of examined nodes with reference to the standard of 12.Materials and MethodsWe evaluated all patients undergoing surgery alone for stage II colon cancer included in our colorectal cancer database since 1976.ResultsA total of 901 patients were included. Mean follow-up exceeded 8xa0years. The individual pathologist had no statistically significant association with the number of lymph nodes examined. Harvest of at least 12 nodes was related to surgery after 1991 (85% vs 69%, Pxa0<xa00.001), right vs left colon carcinomas (85% vs 72%, Pxa0<xa00.001), individual surgeon (Pxa0=xa00.018), and length of specimen at different cutoffs of at least 30, 25, and 20xa0cm (Pxa0<xa00.001). Increasing age was associated with fewer examined lymph nodes (Spearman correlationxa0=xa0−0.22, Pxa0<xa00.001). Fewer than 12 nodes and T4N0 staging independently affected overall survival (Pxa0=xa00.003 and Pxa0=xa00.022, respectively), disease-free survival (Pxa0=xa00.010 and Pxa0=xa00.09, respectively), disease-specific mortality (Pxa0=xa00.009 and Pxa0<xa00.001, respectively), and overall recurrence (Pxa0=xa00.13 and Pxa0=xa00.023, respectively). A minimal number of more than 12 examined nodes had no significant effect on cancer outcomes.ConclusionsA number of factors influenced lymph node harvest in stage II colon cancer. However, lymph node assessment of at least 12 nodes was the only modifiable factor optimizing cancer outcomes.

Sacral neuromodulation for the treatment of fecal incontinence and urinary incontinence in female patients: long-term follow-up

PurposeThe purpose of this study was to evaluate improvement in symptoms of fecal incontinence (FI) in a group of women who also had urinary incontinence (UI) and were successfully implanted with the sacral neuromodulation (SNM) device primarily for urinary incontinence in one US institution.MethodsTwenty-four patients with FI and UI who failed to improve with conservative or standard surgical treatment underwent permanent SNM after a successful peripheral nerve stimulation test during 2003–2007. Wexner incontinence score, fecal incontinence quality of life (FIQL), and Bristol stool scales were recorded before and after treatment. Follow-up was done by questionnaires contact.ResultsTwenty-four patients (mean age 56.5u2009±u20095.3xa0years) were studied. The median follow-up was 28xa0months (range 3–49). Twenty-two patients (92%) were contacted. Seven patients (31.8%) experienced improvement in both urinary and fecal incontinence symptoms. Twelve patients (54.5%) experienced no improvement in FI symptoms after SNM. Four patients required a colostomy or ileostomy; four had the system explanted (two, due to a faded clinical response and two, due to infection); and four other patients experienced no improvement after SNM. The outcomes of ten patients (45.5%) with functioning SNM were reviewed. There were significant improvement of FI symptoms with a significantly lower Wexner score from 12.0u2009±u20092.0 before SNM to 4.7u2009±u20093.6 (pu2009=u20090.009). The mean FIQL scores improved significantly from the baseline score 7.8u2009±u20090.8 before SNM to 13.5u2009±u20092.6 (pu2009=u20090.009). Bristol stool form scale was reduced significantly from 4.5 to 3.5 after SNM (pu2009=u20090.02).ConclusionsSNM may be beneficial in selected female patients with UI associated with FI. Prospective trials may help delineate which patients will show FI improvement in this combined group.