Lawrence C. Rusin

Laparoscopic resection for diverticular disease

PURPOSE: The role of laparoscopic surgery in treatment of patients with diverticulitis is unclear. A retrospective comparison of laparoscopic with conventional surgery for patients with chronic diverticulitis was performed to assess morbidity, recovery from surgery, and cost. METHODS: Records of patients undergoing elective resection for uncomplicated diverticulitis from 1992 to 1994 at a single institution were reviewed. Laparoscopic resection involved complete intracorporeal dissection, bowel division, and anastomosis with extracorporeal placement of an anvil. RESULTS: Sigmoid and left colon resections were performed laparoscopically in 25 patients and by open technique in 17 patients by two independent operating teams. No significant differences existed in age, gender, weight, comorbidities, or operations performed. In the laparoscopic group, three operations were converted to open laparotomy (12 percent) because of unclear anatomy. Major complications occurred in two patients who underwent laparoscopic resection, both requiring laparotomy, and in one patient in the conventional surgery group who underwent computed tomographic-guided drainage of an abscess. Patients who underwent laparoscopic resection tolerated a regular diet sooner than patients who underwent conventional surgery (3.2±0.9vs.5.7±1.1 days;P<0.001) and were discharged from the hospital earlier (4.2±1.1vs.6.8±1.1 days;P<0.001). Overall costs were higher in the laparoscopic group than the open surgery group (

The Fate of the Ileal Pouch in Patients Developing Crohn’s Disease

10,230±49.1vs.

Evolutionary Changes in the Pathologic Diagnosis After the Ileoanal Pouch Procedure

7,068±37.1;P<0.001) because of a significantly longer total operating room time (397±9.1vs.115±5.1 min;P<0.001). Follow-up studies with a mean of one year revealed two port site infections in the laparoscopic group and one wound infection in the open group. Of patients undergoing conventional resection, one patient experienced a postoperative bowel obstruction that was managed nonoperatively, and, in one patient, an incarcerated incisional hernia developed that required urgent laparotomy. CONCLUSIONS: Laparoscopic resection in patients with chronic diverticulitis is safe, with faster recovery and shorter hospital stay compared with conventional open surgery. Higher cost of operating room usage time makes the laparoscopic technique difficult to justify economically. Simplification of operating room use and better case selection may improve cost-effectiveness of the laparoscopic approach.

Unilateral pudendal neuropathy

PURPOSERecent studies have suggested that a subset of patients with Crohn’s colitis may have a favorable outcome after ileal pouch-anal anastomosis and have advocated elective ileal pouch-anal anastomosis in selected patients with Crohn’s disease. We have not offered ileal pouch-anal anastomosis to patients with known Crohn’s disease, but because of the overlap in clinical presentation of ulcerative colitis and indeterminate colitis, some patients receiving an ileal pouch-anal anastomosis are subsequently found to have Crohn’s disease. We review our experience with these patients to identify potential preoperative predictors of ultimate pouch failure.METHODSPatients with a final diagnosis of Crohn’s disease were identified from an ileal pouch-anal anastomosis registry. These patients are followed prospectively. Preoperative and postoperative clinical and pathologic characteristics were evaluated as predictors of outcome. Median (range) values are listed.RESULTSThirty-two (18 females) patients (4.1 percent) with a final diagnosis of Crohn’s disease were identified from a registry of 790 ileal pouch-anal anastomosis patients (1980–2002). Patients underwent ileal pouch-anal anastomosis in two stages (11 patients) or three stages (21 patients). The preoperative diagnosis was ulcerative colitis in 24 patients and indeterminate colitis in 8 patients. Median follow-up was 153 (range, 13–231) months. The median time from ileal pouch-anal anastomosis to diagnosis of Crohn’s disease was 19 (range, 0–188) months. Complications occurred in 93 percent, including perineal abscess/fistula (63 percent), pouchitis (50 percent), and anal stricture (38 percent). Pouch failure (excision or current diversion) occurred in nine patients (29 percent) at a median of 66 (range, 6–187) months. Two of these 9 patients had preoperative anal disease (not significant). Comparing patients with failed pouches (n = 9) to patients with functioning pouches (n = 23), post-ileal pouch-anal anastomosis perineal abscess (67 vs. 26 percent, P = 0.05) and pouch fistula (89 vs. 30 percent, P = 0.01) were more commonly associated with pouch failure. Preoperative clinical, endoscopic, and pathologic features were not predictive of pouch failure or patient outcome. For those with a functional pouch, 50 percent have been or are currently on medication to treat active Crohn’s disease. This group had six bowel movements in 24 (range, 3–10) hours, with leakage in 60 percent and pad usage in 45 percent.CONCLUSIONSPatients who undergo ileal pouch-anal anastomosis and are subsequently found to have Crohn’s disease experience significant morbidity. Preoperative characteristics, including the presence of anal disease, were not predictive of subsequent pouch failure. We choose not to recommend the routine application of ileal pouch-anal anastomosis in any subset of patients with known Crohn’s disease.

Benefits of hand-assisted laparoscopic Restorative proctocolectomy: A comparative study

PURPOSE: Inadequate initial differentiation between ulcerative colitis and Crohns disease may lead to a diagnosis of indeterminate colitis. Construction of an ileoanal pouch in these patients may result in significant morbidity and pouch failure when the ultimate diagnosis is Crohns disease. METHOD: We prospectively studied 543 patients with idiopathic inflammatory bowel disease to determine whether a patients pathologic diagnosis changed with time and how it affected outcome. RESULTS: Preoperative diagnosis was ulcerative colitis in 499 patients, indeterminate colitis in 42 patients, and Crohns disease in 2 patients. Prior colectomy was performed in 58 percent of patients with ulcerative colitis and in all patients with indeterminate colitis and Crohns disease. Postoperatively, the diagnosis changed in 20 patients with ulcerative colitis (13 to indeterminate colitis, 7 to Crohns disease). Another two patients with indeterminate colitis showed evidence of Crohns disease in the resected rectal specimen. As patients were followed up, an additional 13 patients were found to have Crohns disease (5 indeterminate colitis, 8 ulcerative colitis). With the current diagnosis, perineal complications and pouch failure occurred, respectively, in 23 and in 2 percent of patients with ulcerative colitis, in 44 and in 12 percent of patients with indeterminate colitis, and in 63 and in 37 percent of patients with Crohns disease. Pathologic diagnosis was altered in 35 patients (6 percent) overall, with a 12-fold increase in the diagnosis of Crohns disease. Only 3 percent of patients with ulcerative colitis compared with 13 percent of patients with indeterminate colitis had a change in diagnosis to Crohns disease (P=0.006; Fishers exact test). CONCLUSION: Pouch-related complications, eventual pouch failure, and discovery of underlying Crohns disease occurred in a significant number of patients with a diagnosis of indeterminate colitis. Until more accurate diagnostic differentiation is available, caution is advised in recommending the ileoanal pouch procedure to patients with indeterminate colitis.

Colonoscopy: its role in cancer of the colon and rectum.

PURPOSE: Obstetric trauma and excessive defecatory straining with perineal descent may lead to pudendal neuropathy with bilateral increase in pudendal nerve terminal motor latencies (PNTML). We have frequently observed unilateral prolongation of PNTML. Diagnostic and therapeutic implications of unilateral pudendal neuropathy are discussed. METHODS: Records of 174 patients referred to pelvic floor laboratory for anorectal manometry and PNTML testing were reviewed. Computerized anal manometry was performed using dynamic pressure analysis, and PNTML was determined using a pudendal (St. Marks) electrode. RESULTS: No response was elicited from pudendal nerves to electric stimulation from both sides in 14 patients (8 percent) and from one side in 24 patients (13.8 percent). Bilateral PNTML determination was possible in only 136 patients (78 percent), of whom 83 patients (61 percent) had no evidence of neuropathy, revealing normal PNTML on both sides. Of 53 patients (39 percent) with delayed conduction in pudendal nerves, in 15 patients (28 percent), PNTML was abnormally prolonged on both sides, with an abnormal mean value for PNTML. In the remaining 38 patients (72 percent), PNTML was abnormal on one side: in 27 patients with an abnormal mean PNTML and in 11 patients with a normal mean PNTML. CONCLUSIONS: A significant number of patients with pelvic floor disorders have only unilateral pudendal neuropathy. Patients with unilaterally prolonged PNTML should be considered to have pudendal neuropathy, despite normal value for mean PNTML. This fact may be relevant in planning surgical treatment and in predicting prognosis of patients with sphincter injuries.

Hand-assisted laparoscopic sigmoid colectomy: helping hand or hindrance?

PURPOSE:Hand-assisted laparoscopic colectomy is thought to facilitate colonic mobilization while maintaining the benefits of laparoscopic surgery. Although previous studies of hand-assisted colectomy have focused on segmental colonic resection, the use of hand-assisted laparoscopic restorative proctocolectomy has not been investigated. This study evaluated the effectiveness of hand-assisted laparoscopic approach compared with a conventional laparoscopic method in patients undergoing restorative proctocolectomy.METHODS:From a prospective database, a consecutive series of patients were identified undergoing conventional and hand-assisted laparoscopic restorative proctocolectomy and results were compared. Twenty-three patients, comprising 10 hand-assisted and 13 conventional laparoscopic patients, were identified. Patient characteristics, perioperative parameters, and outcomes were assessed.RESULTS:Both groups were well matched with no differences in age, gender, body mass index, operative indication, diagnosis, comorbidity, or steroid usage. There were no differences among incision size between the hand-assisted (8 (range, 8–20) cm) and conventional laparoscopic cases (8 (range, 5–10) cm). The median operative time was significantly shorter in the hand-assisted group (247 (range, 210–390) minutes) compared with the conventional laparoscopic group (300 (range, 240–400) minutes; P < 0.01). The length of stay was similar between groups (hand-assisted: 4 (range, 3–13) days vs. conventional: 6 (range, 4–17) days). Complications occurred in four hand-assisted patients (40 percent; 2 ileus, mechanical obstruction, and dehydration) and in four patients undergoing conventional laparoscopic method (31 percent; 2 anastomotic leak, ileus, and mechanical obstruction).CONCLUSIONS:Compared with conventional laparoscopic restorative proctocolectomy, the hand-assisted method resulted in a significant reduction in operative time without detriment to bowel function, length of stay, or patient outcome. The hand-assisted approach to restorative proctocolectomy is likely to replace conventional laparoscopic methods as the preferred laparoscopic approach for this technically challenging procedure.

Life-threatening hemorrhage and exsanguination from Crohn's disease

In order to determine the feasibility, yield, and impact of routine total colonoscopy on the management of large-bowel cancer 157 cancer patients underwent 175 colonoscopic procedures; 13.6 per cent of the cancers had been missed on double-contrast barium enema examination.Among 92 patients undergoing perioperative colonoscopy, the lesion was reached in 89 per cent and the cecum in 60 per cent; 7.6 per cent demonstrated synchronous cancers, all curable, and all missed on barium-enema examination.Seventy-eight patients underwent colonoscopy at an average of 3.7 years after treatment of the index cancer; 7.7 per cent demonstrated metachronous cancers, all curable, two-thirds of which were missed on barium-enema examination.Benign polyps were noted in 62 per cent of the patients studied; 77 per cent of those polyps, 1 cm or greater in size, were missed on barium-enema examination. Polyps were found proximal to the cancer in 60 per cent of the patients with polyps. Approximately 85 per cent of those with multiple cancers demonstrated benign polyps. Preoperative total colonoscopy with periodic postoperative colonoscopy at an interval of three to five years are essential in the reliable detection of synchronous cancers and for the detection of metachronous cancers at an earlier, more favorable stage.

Functional results after perineal complications of ileal pouch-anal anastomosis.

BackgroundHand-assisted laparoscopic colectomy has been introduced as an alternative to the standard laparoscopic technique, but it has not yet been established whether it offers the same benefits. Therefore, we compared the outcome of patients undergoing hand-assisted laparoscopic sigmoid resection (HALSR) to that of those undergoing laparoscopic sigmoid resection (LSR).MethodsThe study population comprised a sequential series of consecutive patients undergoing elective laparoscopic sigmoid/left colectomy. Values are reported as mean (range).ResultsThere were 85 LSR patients and 66 HALSR patients, with no differences in patient demographics or diagnoses. There were slight differences in operative time favoring HALSR (LSR 205 min (90–380) vs HALSR 189 min (120–290); p = 0.07), and the extraction incision was larger in the HALSR group (LSR 6.2 cm (3–25) vs HALSR 8.1 cm (7–12); p < 0.01). There was no difference in time for return of bowel function (LSR 2.8 days (1–15) vs HALSR 2.5 days (1–8); p = 0.31) or length of hospital stay (LSR 5.0 days (2–17) vs HALSR 5.2 days (3–22); p = 0.73). Complications were similar in the two groups (LSR 23% vs HALSR 21%), but there were fewer conversions in the hand-assisted group (HALSR 0% vs LSR 13%; p < 0.01).ConclusionsHand-assisted laparoscopic sigmoid resection yields the same outcomes as standard laparoscopic techniques, but with fewer conversions. Hand-assistance is a helpful innovation that may expand the application of laparoscopic colectomy.

Is routine pouch surveillance for dysplasia indicated for ileoanal pouches

PURPOSE AND METHODS: From 1979 through 1991, four patients of 631 admissions (0.6 percent) for Crohns disease in Erie, Pennsylvania, presented with life-threatening gastrointestinal hemorrhage. These and 34 similar cases from the medical literature were reviewed to provide a composite of those at risk and elucidate appropriate diagnostic and therapeutic maneuvers. RESULTS: The study revealed a preponderance of young men (2∶1 ratio) with an average age of 35 (range, 14–89) years, the majority of whom had known Crohns disease (60 percent) for an average of 4.6 (range, 0–18) years. The site of bleeding resembled the general distribution for Crohns disease, with small bowel disease predominating (66 percent involved the ileum). The five cases of exsanguination (13 percent of the total) were all men with known Crohns disease (average, 58 years) involving the ileum alone or in part. Mesenteric arteriography was positive in 17 patients, providing precise preoperative localization resulting in no mortality in this group. Excluding those who presented with exsanguination, surgery was necessary to cease hemorrhage in 91 percent (30/33) of patients. Ileocolectomy was the most frequently performed procedure (53 percent). In follow-up, only one patient required further surgical resection for recurrent bleeding (3.5 percent), and two other patients (7 percent) required further therapy for nonhemorrhagic recurrence. CONCLUSION: Crohns disease may be responsible for life-threatening gastrointestinal hemorrhage and even exsanguination. Many of the characteristics of these patients resemble the general Crohns disease population. Surgical resection provides excellent palliation. A long-term benign course can be expected in this subgroup of Crohns disease patients.