Lester Rosen

Practice parameters for the management of anal fissure. The Standards Task Force American Society of Colon and Rectal Surgeons.

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.

Surgical resection in Crohn’s disease: is immunosuppressive medication associated with higher postoperative infection rates?

Aim  The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn’s disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

Management of anorectal horseshoe abscess and fistula.

Over a 10-year period 69 patients were treated consecutively for posterior and anterior horseshoe abscesses and fistulas. Fifty-nine patients had posterior and ten had anterior abscesses or fistulas. There were 52 patients with acute abscess. Treatment consisted of incision and drainage, incision and drainage with primary fistulotomy, incision and drainage with primary fistulotomy and counter-drainage, and incision and drainage with insertion of seton. Seventeen patients with chronic fistulas were treated by primary fistulotomy with curettage, or incision and drainage with insertion of seton. Patients were followed from three months to ten years with a mean follow-up of three years. No incidences of incontinence were reported in this series. The overall rate of recurrence was 18 percent, and included only patients with posterior abscesses and fistulas. Recurrence was related to the failure to maintain prolonged drainage in the midline after primary fistulotomy. The use of seton for delayed fistulotomy appears to promote wound drainage and precludes premature wound closure. More liberal use of the seton in the treatment of horseshoe abscesses and fistulas is advocated.

Metronidazole vs. erythromycin, neomycin, and cefazolin in prophylaxis for colonic surgery.

A prospective, double-blind, randomized study was undertaken to compare perioperative parenteral metronidazole and erythromycin. One neomycin, and cefazolinhundred fifty-five patients were randomized into two groups by the pharmacy department. The resulting difference between the overall septic complication rate in patients receiving erythromycin, neomycin, and cefazolin (10.9 percent) and the rate in patients receiving metronidazole alone (31.9 percent) was significant. This indicates that an antibiotic to cover aerobic bacteria should be added to the regimen when metronidazole is used.

Transanal endoscopic microsurgery for excision of rectal lesions: technique and initial results.

The aim of this study was to review experience with transanal endoscopic microsurgery (TEM) and to assess its applicability to an existing practice of colorectal surgeons. Patients undergoing TEM excision of rectal lesions from March 1997 through May 1999 were selected for this study. Medical records were reviewed retrospectively to obtain pertinent data, including indications for TEM, tumor size, distance from anal verge, duration of operation, completeness of tumor resection, postoperative complications, duration of stay and follow-up, and recurrence. Thirty-one patients underwent TEM during the 2-year period. Indications for TEM included benign disease in eight patients and cancer in 23 patients. Mean distance of the tumor from the anal verge was 8.3 cm. Mean size of the lesion was 2.8 cm, and mean specimen size was 4.5 cm. Larger specimen sizes allowed for tumors to be removed with negative margins (97%) in all cases but one. Mean duration of operation was 140 minutes (including set-up time), and mean duration of hospital stay was 1.2 days. Major postoperative complications occurred in one patient. Mean duration of follow-up was 15 months, and recurrence developed in two patients during this period. Transanal endoscopic microsurgery excision of rectal lesions with negative margins was possible in 97% of cases with minimal morbidity and a short-duration hospital stay. Follow-up was too brief to evaluate recurrence, but the thoroughness of resection of tumor in a high proportion of cases is promising.

Granulomas in Crohn's disease: does progression through the bowel layers affect presentation or predict recurrence?

Aim  The aim of the study was to correlate the presence and pattern of distribution of granulomas in resected specimens to clinical characteristics and outcome in patients undergoing surgery for Crohn’s disease.

Endoscopic retrieval of foreign bodies from the rectum

A technique is described and illustrated by case reports wherein removal of foreign bodies of the rectum is simplified by using the flexible sigmoidscope. Evidence from the literature indicates that delayed perforation is rare in this situation, and that outpatient management would suffice for most patients.

V-Y advancement for anal ectropion

A V-Y advancement flap modified for anorectal use in reconstructive surgery for anal ectropion is described. The underlying exteral sphincter serves a dual function as the pivotal point for flap advancement and as the vascular pedicle to the dermal-subdermal plexus supplying the flap. This ensures viability and restores function to the newly created anus.

Optimizing rectal cancer management: Analysis of current evidence

Diseases of the Colon & ReCtum Volume 57: 2 (2014) Colorectal carcinoma remains the second leading cause of cancer-related deaths in Western countries, with rectal carcinoma accounting for ≈25% of cases arising from the large bowel. Rectal cancer affects more than 40,000 patients annually in the united states, and a majority of these patients undergo surgery, with approximately half dying as a consequence of their disease. therefore, rectal cancer represents a significant healthcare problem in terms of incidence, seriousness, and use of resources. historically a huge variation among surgeons has been described in results of colorectal cancer surgery, with statistically significant differences in curative resection, postoperative morbidity and mortality, and long-term survival. Rectal cancer surgery is considered more technically challenging compared with colon cancer surgery, mainly because of the anatomy of the pelvis and the resulting challenge that a surgeon faces in achieving good resection margins in a confined, fixed bony space in close proximity to vital structures. historically these challenges have been reflected in poorer oncologic results, with local recurrence rates approaching 30% and worse overall survival in comparison with that of colon cancer. in the united states, the majority of rectal cancer surgeries have traditionally been performed by trained general surgeons, who may or may not have a colorectal subspecialty interest. studies indicate that there is significant room for improvement in the outcomes of rectal cancer surgery, with significant variation in results including rates of margin positivity, local recurrence, use of neoadjuvant and adjuvant therapy, and permanent stomas. some reports indicate variations in local recurrence rates of between 0% and 13% for colorectal surgeons and between 21% and 37% for general surgeons. Differences in mortality also exist, with rates of 1.4% for colorectal surgeons and >7.0% for general surgeons being reported. in a recent study of proctectomies, restorative techniques were used in 50% of patients, with abdominoperineal resection rates as high as 60% in some regions. in addition, approximately one fifth of proctectomies were performed by a specialist colorectal surgeon, and ≈40% of the surgeons only performed nonrestorative surgery. the management of rectal cancer has fundamentally changed in the last 3 decades with the introduction of staging, total mesorectal excision (tme), chemoradiotherapy (CRt), and multidisciplinary management. since the 1980s, 5 main principles have been developed that, when combined, have led to significant reductions in rates of local recurrence, increases in disease-free and overall survival, and reduction in permanent stoma rates. in countries and centers that have implemented such programs, the cancer-specific outcomes from rectal cancer now match those of colon cancer for the first time. the principles include the following: 1) rectal surgery according to the principles of tme, 2) measurement of quality of surgery and accurate staging by specific techniques of pathology assessment, 3) specialist imaging techniques identifying Optimizing Rectal Cancer Management: Analysis of Current Evidence

Perineal rectosigmoidectomy for primary and recurrent rectal prolapse: are the results comparable the second time?

BACKGROUND: The surgical approach to recurrent full-thickness rectal prolapse after perineal rectosigmoidectomy is complicated by recurrent prolapse. The majority of patients who undergo perineal rectosigmoidectomy are elderly with comorbidities. Therefore, redo perineal rectosigmoidectomy is usually selected to avoid postoperative complications. OBJECTIVE: This study aimed to evaluate the safety and efficacy of redo perineal rectosigmoidectomy for recurrent full-thickness rectal prolapse. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at Cleveland Clinic Florida, from January 2000 to March 2009. PATIENTS: One hundred thirty-six patients (129 women), mean age 78 (range, 31–98) years, were included in the study; 113 patients with full-thickness rectal prolapse underwent primary perineal rectosigmoidectomy, and 23 patients with recurrent full-thickness rectal prolapse underwent redo perineal rectosigmoidectomy. INTERVENTIONS: All patients underwent perineal rectosigmoidectomy. MAIN OUTCOME MEASURES: Perioperative outcomes, recurrence curves, and risk of recurrence were compared between the 2 groups. Age, anterior compartment prolapse, concurrent levatorplasty, and length of bowel resection were analyzed to identify factors potentially influencing recurrence. RESULTS: Both groups had comparable demographics, BMI, and ASA scores. Operative time, blood loss, length of bowel resection, hospital stay, and follow-up (mean, 42.5 months) were similar in both groups. There was no significant difference in overall complication rates (redo perineal rectosigmoidectomy 17.4% vs primary perineal rectosigmoidectomy 16.8%; p = 1.00). The recurrence rate for full-thickness rectal prolapse was significantly higher for redo perineal rectosigmoidectomy than primary perineal rectosigmoidectomy (39% vs 18%; p = 0.007). None of the factors analyzed was associated with recurrence in either group. LIMITATIONS: This study was limited by its retrospective methodology. In addition, functional outcomes were not evaluated, because many of the patients died during the follow-up period or were unavailable because of advanced age. CONCLUSIONS: Redo perineal rectosigmoidectomy is as safe and feasible as primary perineal rectosigmoidectomy in elderly and fragile patients with recurrent full-thickness rectal prolapse. However, the re-recurrence rate for full-thickness rectal prolapse is substantially higher for redo perineal rectosigmoidectomy than primary perineal rectosigmoidectomy.