Juan García-Armengol

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

Aim: A prospective review of the complications of ileostomy construction and takedown. Materials and Methods: One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared. Results: One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterior resection for low rectal carcinoma, 30 an ileoanal pouch for ulcerative colitis and 25 for miscellaneous conditions. Fifty-nine pre-takedown complications occurred in 50 (39.4%) patients. The most common were dermatitis (12.6%) and erythema (7.1%). The most severe were dehydration in 1 patient and stomal prolapse in 4 patients. Closure was associated with a complication rate of 33.1% and a mortality rate of 0.9%. Wound infection occurred in 18.3% and small bowel obstruction in 4.6%. Anastomotic leak requiring reanastomosis occurred in 2.8% and enterocutaneous fistula treated conservatively in 5.5%. There were no statistically significant differences in morbidity between closure techniques (p = 0.892). There were no statistically significant differences in complications (p = 0.516) between patients with ulcerative colitis and those with neoplasia (39.29% vs. 32.2%). Conclusions: Loop ileostomy construction and takedown is associated with considerable morbidity, mostly minor. No differences exist between technique used for closure or the baseline pathology of the patient.

Impact of surgeon organization and specialization in rectal cancer outcome.

The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery.

Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy.

PURPOSE: The present study was undertaken to evaluate anal endosonographic results of the transverse and longitudinal extent of internal anal sphincter division after closed lateral subcutaneous sphincterotomy and its relationship to outcome with respect to anal fissure recurrence and postoperative anal incontinence. METHODS: Ten patients selected for symptomatic anal fissure recurrence (mean follow-up, 10.9 months) and 41 asymptomatic control patients (mean follow-up, 15.5 months) were reviewed by anal endosonography after closed lateral subcutaneous sphincterotomy. Clinical evaluation was focused on anal fissure recurrence and postoperative anal incontinence. The anal endosonographic study involves serial radial images of the distal, proximal, and midanal canal. RESULTS: In 32 patients in whom a complete internal sphincter defect was identified, 31 (75.6 percent) were from the control group and only 1 patient (10 percent) was from the recurrence group (P<0.001). In 19 patients, an incomplete internal sphincter defect was identified; 10 (24.4 percent) were from the control group (residual median size, 1.8 mm; contralateral, 2.5 mm) and 9 patients (90 percent) were from the recurrence group (P=0.001; residual median size, 1.4 mm; contralateral, 2.2 mm). Ten patients (19.6 percent) were incontinent for gas and three patients (5.9 percent) for liquid feces, without significant differences between groups. CONCLUSIONS: Anal endosonography is a useful method for evaluating the anatomic effectiveness of closed lateral subcutaneous sphincterotomy. An incomplete sphincterotomy is associated with significant symptomatic anal fissure recurrence.

Risk factors for recurrence and incontinence after anal fistula surgery

Objective  Fistula‐in‐ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors.

Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery.

PURPOSE: This study aimed to analyze changes in anal continence and morphologic and functional anorectal variables after fistula-in-ano surgery in a patient series with a high rate of complex fistulas. METHODS: One hundred twenty patients with a mean age of 46.9 (standard deviation, 12.8) years were prospectively analyzed by evaluating anal continence, results of endoanal ultrasound examination and anorectal manometry, and pudendal nerve terminal motor latency before and after fistula-in-ano surgery. RESULTS: Forty-three patients (35.8%) were referred for recurrent fistulas; fistulas in and 70 (58.3%) were considered complex. Preoperatively, 17 patients (14.2%) presented with impaired continence. At follow-up, 59 patients (49.2%) had some degree of incontinence (P < 0.001). The techniques that most affected continence were rectal advancement flap and fistulotomy. Endoanal ultrasound examination showed that the number of patients with internal anal sphincter defects increased from 37 (30.8%) to 78 (74.3%) after surgery (P < 0.001); those with external anal sphincter defects increased from 17 (15.9%) to 34 (32.4%) (P < 0.001). Techniques most associated with increases in internal anal sphincter defects were fistulotomy (P < 0.003) and rectal advancement flap (P < 0.004). Anal manometry showed significant decreases in maximal resting pressure and maximum squeeze pressure in patients with previous incontinence (P < 0.001), and in those with internal anal sphincter defects (P < 0.001). Fistulotomy decreased both resting pressure (P < 0.004) and squeeze pressure (P < 0.007), whereas rectal advancement flap significantly reduced only resting pressure. Pudendal nerve latency did not differentiate continent and incontinent patients, and showed no postoperative change. CONCLUSIONS: Anal continence is significantly affected after fistula-in-ano surgery, mainly because of sphincteric lesions that affect anal canal pressures and that can be imaged with endoanal ultrasound. It is important to preoperatively recognize sphincter defects to allow adequate surgical treatment.

Review of the anatomic concepts in relation to the retrorectal space and endopelvic fascia: Waldeyer’s fascia and the rectosacral fascia

Objective  A precise anatomical study of the fascias within the retrorectal space is reported, analyzing and clarifying the anatomical concepts previously employed to describe Waldeyer’s and the rectosacral fascia.

Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas

Objective  Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques.

Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons

Objective  Antibiotic prophylaxis (AP) and mechanical bowel preparation (MBP) previous to surgery have classically been regarded as important in colorectal surgery. The latter has recently been questioned. We evaluated opinion of Spanish surgeons about the use of these measures.

Prospective study of morphologic and functional changes with time in the mucosa of the ileoanal pouch: Functional appraisal using transmucosal potential differences

PURPOSE: This study was undertaken to investigate the morphologic and functional changes with time in the mucosa of the ileoanal pouch. METHODS: A morphologic study by histopathologic analysis, mucosal morphometry, and mucin histochemistry and a functional study by analysis of transmucosal potential difference were performed in 27 patients with an ileoanal J-pouch after restorative proctocolectomy for ulcerative colitis. In 19 patients with a normal ileoanal pouch, two prospective follow-up analyses were performed after median functional pouch times of 14 and 39 months. We also evaluated eight patients with the diagnosis of pouchitis (median follow-up, 52.5 months). RESULTS: In the normal ileoanal pouch group, some degree of chronic and acute inflammatory infiltration was identified in 100 percent and 63.2 percent of cases, respectively, with no significant differences being observed between the two follow-up analyses. The mean villous atrophy index at the first and second follow-up was 0.54 and 0.52, respectively, significantly lower (P<0.001; an indication of a greater degree of villous atrophy) than the value obtained from the control group with a healthy terminal ileum (0.77). The group of patients with pouchitis exhibited statistically significant differences in the degree of acute and chronic inflammatory infiltration, the extent of ulceration, the crypt depth, and the villous atrophy index, compared with patients without pouchitis. In the normal ileoanal pouch group, the median percentage of sulfomucin with each degree of atrophy (1=mild; 2=moderate; and 3=severe) was 2.6, 4.5, and 20.9 percent, respectively. In patients with pouchitis, the median percentage of sulfomucin was 5.9 percent. The mean transmucosal potential difference at the first follow-up (−25.3 mV) was significantly lower (P=0.001) than at the second (−30.4 mV). Significant differences were apparent with respect to both the normal ileum (−8.9 mV) and the normal rectum (−40.2 mV). CONCLUSION: These results suggest that the ileal pouch behaves as a neorectum, with different degrees of colonic metaplasia from a morphologic and a functional perspective.

Management of colonic volvulus. Experience in 75 patients.

BACKGROUND the diagnostic and therapeutic management of colonic volvulus remains nowadays controversial. The election of the type of surgery, its timing, or the use of non-operative decompression must be based on the experience of a multidisciplinary team, the clinical condition of the patient, and the type of volvulus. OBJECTIVES the purpose of this study is to review our experience and results in the treatment of patients with colonic volvulus. MATERIAL AND METHODS we performed a retrospective study of patients diagnosed of colonic volvulus between January 1990 and September 2008 in our institution. RESULTS we included a total of 75 patients with a mean age of 72.7 years and, in most cases, with associated comorbidities and constipation. The most frequently involved segment was sigmoid colon (85.3%). A rectal tube insertion was used as the only therapeutic measure in 17 patients (22.4%), colonoscopic decompression in 17 (22.4%), and surgery in 41 patients (55.2%). Intestinal resection with primary anastomosis was the most common surgical option. Postoperative morbidity was 43%, being wound infections the most frequent complication. In the group of non-surgical treatment morbidity was 26.4%, albeit with a higher and early rate of recurrences. CONCLUSIONS treatment of colonic volvulus present important morbidity and mortality rates, and its treatment must be individualized. Resective surgery with primary anastomosis in clinically stable patients is the most appropriate therapeutic option, offering the lower recurrence rates.