M. K. Baig

Determinants of Recurrence After Sigmoid Resection for Uncomplicated Diverticulitis

AbstractPURPOSE: This study aimed to evaluate the impact of surgery-associated variables on recurrence rates after sigmoid resection for diverticulitis. nMETHODS: Patients who underwent elective sigmoid resection for uncomplicated diverticulitis between 1992 and 2000 at two tertiary referral centers were followed up for recurrent disease as the primary end point. Recurrence after surgery was defined as left lower quadrant pain, fever, and leukocytosis, with consistent CT and/or contrast enema findings on admission and after six weeks. A logistic regression of the following variables was undertaken: patient demographics, duration of preoperative symptoms, previous admissions and abdominal surgery, surgical access (laparoscopic or open), postoperative complications, splenic flexure mobilization, anastomotic technique (handsewn or stapled), specimen length, inflammation at proximal resection margin, and anastomotic level (colosigmoid or colorectal). The last three variables were defined by the pathologist. Anastomosis level was based on muscle layer configuration (taeniae coli) at the distal resection margin. nRESULTS: Two hundred thirty-six patients (105 females) with a mean age of 60.4 (standard deviation, ± 10) years were available for follow-up at 67 ± 30 (range, 11–130) months. The median duration of preoperative symptoms was 18 (range, 12–120) months. All but one (99 percent) patient had at least one admission before surgery. One hundred forty (59 percent) and 96 (41 percent) patients underwent laparoscopic or open resection, respectively. The conversion rate was 13 percent (18 patients) in the former group and the 30-day complication rate was 23 percent, with 0.4 percent 30-day mortality and a 2.1 percent reoperation rate. The splenic flexure was mobilized in 109 patients (47 percent). Anastomoses were fashioned by stapler in 171 patients (73 percent) and were to the rectum in 143 patients (72 percent). Specimen length was 17.9 ± 5.9 (range, 9–47) cm with inflammation at the proximal margin in 30 patients (14 percent). Twelve (5 percent) patients developed a recurrence at a mean of 78 ± 25 (range, 34–109) months with reoperation in one (0.4 percent). The level of anastomosis was the only predictor of recurrence in regression analysis (P = 0.033). Patients with colosigmoid anastomosis had a four times higher risk of having a recurrence compared with patients with colorectal anastomosis (odds ratio, 95 percent confidence interval = 1.12, 14.96). nCONCLUSION: Colorectal (rather than colosigmoid) anastomosis was the single predictor of lower recurrence rates after elective sigmoid resection for uncomplicated diverticulitis.

Does limited placement of bioresorbable membrane of modified sodium hyaluronate and carboxymethylcellulose (Seprafilm®) have possible short-term beneficial impact?

PURPOSE: The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm®) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity. METHODS: All patients who had Seprafilm® placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm®. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fishers exact test was used to compare gender distribution, nature of diagnosis (inflammatoryvs. noninflammatory), and urgency of surgery (electivevs. emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Studentst-test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan-Meier product limit method and log-rank test. RESULTS: Two hundred fifty-nine patients in whom Seprafilm® was placed were compared with a well-matched control cohort of 179 patients. The two groups did not differ in gender or age. One-half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm® group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm® group and 12 intestinal obstructions in 11 patients in the control group at a follow-up period of 65 months in the Seprafilm® group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm® group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm® group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm®. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm® (3.4 percent) and control (1.1 percent) groups. CONCLUSION: During short-term follow-up in this nonprospective, nonrandomized study, limited placement of Seprafilm® did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long-term, prospective, randomized trial is underway to elucidate these issues.

Anal ultrasound and endosonographic measurement of perineal body thickness: a new evaluation for fecal incontinence in females.

BackgroundPerineal body thickness (PBT) is measured by endoanal ultrasonography. The literature has shown that women with obstetric trauma to the anal sphincter have decreased PBT, and a measurement of 10xa0mm or less has been proposed as abnormal. Therefore, this study aimed to compare the proposed definitions of normal to pathologic findings in patients with fecal incontinence (FI) and to correlate PBT with anorectal physiologic findings.MethodsAll female patients who had endoanal ultrasonography and PBT measurement for evaluation of FI were assessed and divided into three groups on the basis of PBT: 10xa0mm or less, 10 to 12xa0mm, more than 12xa0mm. The degree of FI (0 = complete continence; 20 = complete incontinence) was correlated with PBT.ResultsFor this study, 83 female patients with a mean age of 59.7xa0years (range, 30–88xa0years) had endoanal ultrasonography and PBT measurement. Sphincter defects were suggested by endoanal ultrasonography in 77% of the patients in the three groups as follows: 57 (97%) of 59 patients, 4 (36%) of 11 patients, and 3 (23%) of 13 patients. The mean external sphincter defect angle was 110° (range, 45–170°), and the mean FI score was 13.8. For 89% of the patients there was a history of vaginal delivery. As reported, 35% had undergone one or more prior perineal surgeries, 27% had both, and 4% denied having had either. A significant correlation between sphincter defect and PBT (p < 0.001) was noted. External sphincter defect angles were negatively correlated with PBT (p = 0.001).ConclusionA PBT of 10xa0mm or less is considered abnormal, whereas a PBT of 10xa0mm to 12xa0mm is associated with sphincter defect in one-third of patients with FI. Those with a PBT of 12xa0mm or more are unlikely to harbor a defect unless they previously have undergone reconstructive perineal surgery.

Altered serotonin immunoreactivities in the left colon of patients with colonic inertia

Serotonin is an important positive regulator of colonic motility and transit. Its quantity and distribution in the left colon could be abnormal in patients with colonic inertia (CI) and contribute to the disease.

Formalin Instillation for Hemorrhagic Radiation Proctitis

Although formalin instillation has been proven to be an effective treatment of hemorrhagic radiation proctitis, different tech niques with varying success rates have been reported. The aim of this study was to assess our experience with formalin instillation for the treatment of radiation proctitis. After Institutional Review Board approval, all patients who presented with radiation proctitis and were treated with 4% formalin instillation were identified from a prospective database. Techniques of instillation were as follows: a formalin-soaked sponge stick was applied via a proctoscope (SS) and placed at each quadrant with a mean contact of 2.5 minutes (range, 0.5-3 minutes), or the formalin solution was introduced through a proctoscope in aliquots for a total of 350 to 400 mL irrigation (IR), with a mean contact time of 30 seconds in each aliquot. The patients were divided into two groups according to the method of formalin instillation and their outcomes were compared. Between March 1995 and September 2003, 21 patients who underwent formalin treatment were identified: 17 patients were in the SS and 4 patients were in the IR group. The mean age was 74.8 6.4 years and 70.5 6.8 years and the male/female ratio was 16:1 and 3:1 in the SS and IR groups, respectively. Indications for radiation therapy were prostate cancer in 19 patients: 16 (95.1%) SS patients and 3 (75%) IR patients. Four (23.5%) patients in the SS group were receiving anticoagulants or antiplatelet medications before the procedure. The mean duration of bleeding before formalin instillation was 11.7 months (range, 2-48 months) in the SS and 10.5 months (range, 7-12 months) in the IR group. Sixteen (94.1%) patients in the SS and 4 (100%) in the IR group had previous treatments for radiation proctitis, including hydrocortisone enema, 5-aminosalicylate mesalamine, and endoscopic coagulation. Eight (47.1%) patients in the SS and 2 (50%) in the IR group received a preprocedural blood transfusion, and 1 patient in the SS group required a blood transfusion after the formalin instillation. This patient subsequently underwent restorative proctosigmoidectomy because of persistent bleeding. The mean length of the procedure was 27.1 10.8 minutes in the SS group and 22.5 6.5 minutes in the IR group. The bleeding was successfully stopped on the first attempt in 14 patients (82.4%) in the SS group and 3 (75%) in the IR group. The instillation was repeated in 1 patient (5.9%) in the SS group and in 1 (25%) in the IR group. Four patients (23.5%) in the SS group experienced rectal pain after the procedure. One patient (5.9%) developed a new onset of fecal incontinence, while another (5.9%) had anococcygeal pain accompanied by worsening of fecal incontinence. One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months). Formalin instillation is effective in controlling refractory hemorrhage secondary to radiation proctitis.

Accuracy of hydrogen peroxide enhanced endoanal ultrasonography in assessment of the internal opening of an anal fistula complex.

Abstract.Background:The aim of this study was to evaluate the accuracy ofnhydrogen peroxide-enhanced ultrasound in localizing the internalnopening of the anal fistula.Methods:A retrospective review of all patients with anal fistulanwho underwent hydrogen peroxide-enhanced ultrasound wasnperformed. The results of hydrogen peroxideenhanced ultrasoundnand intraoperative findings on the basis of operative reportsnwere correlated.Results:A total of 57 patients (47 men) of mean age of 45.7n(range, 21–77) years underwent hydrogen peroxide-enhancednultrasound with a diagnosis of anal fistula; 36 patientsnunderwent surgery. The intraoperative internal openingncorrelated with the hydrogen peroxide-enhanced ultrasound reportnin 22 of 36 patients (61.1%). In 5 patients, the hydrogennperoxide-enhanced ultrasound yielded false-positive informationnwith a positive predictive value of 84%. Four of the 7 patientsnwith falsenegative hydrogen peroxide-enhanced ultrasoundnfindings had supra- and extrasphincteric fistulas.Conclusions:There is a 61.1% correlation between hydrogennperoxide-enhanced ultrasound and surgical findings of theninternal opening with a positive predictive value of 84%. If noninternal opening was seen on hydrogen peroxide-enhancednultrasound, it strongly suggests the possibility of ansupralevator or extrasphincteric fistula.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair

AbstractBackgroundAnatomic anal sphincter defectsncan involve the internal anal sphincter (IAS), the externalnanal sphincter (EAS), or both muscles. Surgical repair ofnanteriorly located EAS defects consists of overlappingnsuture of the EAS or EAS imbrication; IAS imbricationncan be added regardless of whether there is IAS injury.nThe aim of this study was to assess the functional outcomenof anal sphincter repair in patients intraoperatively diagnosednwith combined EAS/IAS defects compared tonpatients with isolated EAS defects.MethodsThe medicalnrecords of patients who underwent anal sphincter repairnbetween 1988 and 2000 and had follow-up of at least 3nmonths were retrospectively assessed. Fecal incontinencenwas assessed using the Cleveland Clinic Florida incontinencenscore wherein 0 equals perfect continence and 20 isnassociated with complete incontinence. Postoperativenscores of 0–10 were interpreted as success whereas scoresnof 11–20 indicated failure.ResultsA total of 131 womennwere included in this study, including 38 with combinednEAS/IAS defects (Group I) and 93 with isolated EASndefects (Group II). Thirty-three patients (87%) in Group Inhad imbrication of a deficient IAS, compared to 83npatients (89%) in Group II. All patients had either overlappingnEAS repair (n=121) or EAS imbrication (n=10).nMean follow-up was 30.9 months (range, 3–131 months).nThere were no statistically significant differences betweennthe two groups relative to age (48.3 vs. 53.0 years;np=0.14), preoperative incontinence score (16.1 vs. 16.7;np=0.38), extent of pudendal nerve terminal motor latencynpathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs.n15.1%; p=0.84), extent of pathology at electromyographyn(54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9nvs. 32.5 months; p=0.31). The success rates of sphincternrepair were 68.4% for Group I versus 55.9% for Group IIn(p=NS). Both groups were well matched for incidence ofnIAS imbrication as well as age, follow-up interval, andnphysiologic parameters. The success rates of anal sphincternrepair were not statistically significant between the twongroups.ConclusionA pre-existing IAS defect does notnpreclude successful sphincteroplasty as compared to repairnof an isolated EAS defect. Thus, patients with combinednanal sphincter defects should not be considered as poorncandidates for sphincter repair.

Reduced expression of serotonin receptor(s) in the left colon of patients with colonic inertia

AbstractPURPOSE: Serotonin regulates colonic motility via receptors expressed on neural fibers and smooth muscle. Colonic inertia is characterized by delayed colonic transit. Abnormalities in serotonin receptor protein, as judged by immunoreactivity levels, could contribute to the origin of colonic inertia. The aim of this study was to investigate the expression of serotonin receptor(s) immunoreactivity in the left colon of patients with colonic inertia compared with controls. nMETHODS: Sixteen patients who underwent subtotal colectomy for colonic inertia were assessed. Colonic transit time was measured with the radiopaque marker technique and presented as the number of retained markers in the colon on Day 5. The control group consisted of 18 patients who underwent left hemicolectomy for colonic carcinoma; histologically normal tissues from the left colon were used. Immunohistochemical staining for serotonin receptor was performed with a rabbit anti-idiotypic antibody. The average positive area (square pixels) in the mucosa, muscularis mucosa, submucosa, and circular and longitudinal muscles per microscopic field (63×) was calculated based on measurement of the positively stained area in 20 randomly chosen microscopic fields in each related structure. The Scion Image computer analysis system was used. nRESULTS: Serotonin receptor(s) immunoreactivity was mainly detected in the muscular mucosa, circular muscles, and longitudinal muscles and rarely in the mucosa and submucosa. In muscularis mucosa and circular muscle, the positive areas were significantly less in the colonic inertia group than in controls (muscularis mucosa: 29.1 ± 10.8 vs. 109.7 ± 28.2, P < 0.05; circular muscle: 25.6 ± 6.2 vs.90.2 ± 19.1, P < 0.01). There were significantly positive correlations in the control group in serotonin receptor(s) immunoreactivity levels between circular muscle and longitudinal muscle (r = 0.54, P < 0.05) and between muscular mucosa and longitudinal muscle (r = 0.57, P < 0.05) but not in colonic inertia patients. In addition, the positive areas in the circular muscle were positively correlated to the colonic transit time (Spearman’s rank correlation, 0.83; P < 0.01). nCONCLUSION: In colonic inertia patients, the serotonin receptor(s) immunoreactivity level is lower in muscular mucosa and circular muscle. The absence of a correlation of serotonin receptor(s) immunoreactivity in the muscular mucosa and muscularis propria in the patient group implies that an uncoordinated expression of serotonin receptors may also contribute to colonic inertia. However, the positive correlation between serotonin receptor(s) immunoreactivity levels in the circular muscle and the transit time observed in colonic inertia patients suggests a decrease in stimulatory subtypes and at the same time an increase in inhibitory subtypes of serotonin receptors in this tissue.

Outcome of parastomal hernia repair with and without midline laparotomy.

AbstractBackgroundSurgical options for parastomalnhernia (PSH) repair are primary fascial, mesh repair, andnrelocation with or without midline laparotomy. Overall,nrecurrence rates are higher after fascial repairs than afternrelocation. However, stoma relocation may require a midlinenlaparotomy with higher associated morbidity. Thenaim of this study was to assess the outcome of PSH repairnwith relocation with or without a midline laparotomy.MethodsAll patients who underwent PSH repair withnrelocation were identified from a clinical database. Datanwere collected by retrospective review of medical recordsnincluding patient demographics, presenting symptoms,npredisposing factors, type of surgery, postoperative complications,nrecurrence, and follow-up. Patients werendivided into two subgroups, with or without a midlinenlaparotomy. In patients without a laparotomy, the stomanwas intraperitoneally mobilized, passed behind thenabdominal wall, and delivered and matured through anpremarked stoma site, across the midline.ResultsBetween 1992 and 2001, a total of 27 patients underwentnPSH repair with relocation of the stoma to the oppositenside of the abdominal wall. Of these, the operation wasnperformed without a midline laparotomy in 11 patientsn(41%). There were no significant differences in age, gender,nbody mass index, and the duration of hernia betweennthe non-laparotomy and laparotomy groups. Prior abdominalnsurgery was recorded for 3 patients in the group withoutna laparotomy and for 9 patients in the group with anlaparotomy (p=NS). Although not quantified, patients innthe non-laparotomy group were less likely to have significantnintraabdominal adhesions. Conversely, patients innthe laparotomy group had more advanced adhesions. Thenoperative time was longer in the group with a laparotomynthan in the group without [96.8 (50–220) minutes vs.n123.9 (45–360) minutes; (p=NS)], and the mean hospitalnstay was significantly less in patients without vs. with anlaparotomy [5.5 (SD=1.6) days vs. 9.5 (SD=3.8) days,nrespectively; (p<0.05)]. There was only one recurrence innthe group without a laparotomy compared to 3 in thengroup with a laparotomy. The mean follow-up periodsnwere 36.8 and 56.6 months in the groups without and withna laparotomy, respectively. The postoperative complicationsnincluded wound infection that occurred in 3 patientsnin each group.ConclusionsPSH repair with relocationnwithout laparotomy was associated with a significantlynshorter hospital stay, possibly due to the lack of a midlinenabdominal wound. It may not be feasible in patients withnsignificant intraabdominal adhesions.

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians

Objectiveu2002 Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70u2003years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70u2003years who had IPAA.