Martin Luchtefeld

Colorectal anastomotic stenosis results of a survey of the ASCRS membership

Anastomotic stenosis is a poorly understood and underexamined complication of gastrointestinal surgery, reportedly most frequent in the coloproctostomy. In order to better define this problem, a questionnaire was sent to members of the American Society of Colon and Rectal Surgeons regarding patients with gastrointestinal anastomotic stenosis. A total of 123 patients with intestinal anastomotic stenosis were analyzed. Eighty-two anastomoses were stapled and 41 were handsewn. Nearly all stenoses occurred in the distal bowel (70 rectal, 23 sigmoid colon). Preoperative risk factors identified were obesity (28 patients) and abscess (12 patients). Incomplete “doughnuts” were noted in 12 patients. Postoperative anastomotic leaks (15 patients), pelvic infection (13 patients), and postoperative radiation (7 patients) were believed to be contributing factors. Dilatation, using a variety of techniques, was the sole treatment for 65 patients, however, intra-abdominal surgery was necessary in 34 patients. Large intestinal anastomotic stenosis probably occurs most commonly following coloproctostomy (both with handsewn and stapled anastomoses). Dilatation alone resulted in adequate treatment in most patients in the study. Major surgery was required to correct this problem in a significant number of patients (28 percent) in this series. The true incidence of anastomotic stenosis in colorectal surgery is unknown and warrants further study.

Postoperative Ileus: It Costs More Than You Expect

BACKGROUND The clinical impact of postoperative ileus (POI) after colectomy is difficult to quantify financially because of administrative coding limitations. Accurate data are important to allow pharmaco-economic analysis of methods aimed at reducing POI. The aim of this study was to assess the financial impact of POI for the 30-day episode of care for colectomy. STUDY DESIGN We reviewed all colectomy patients at our institution from July 2007 to June 2008. Primary POI was defined as more than three episodes of emesis with return to NPO diet status and/or reinsertion of nasogastric tube; secondary POI was associated with intraabdominal complications. Readmission for gastrointestinal failure was defined as delayed POI (no radiologic or surgical identification of small bowel obstruction). All other complications requiring readmission were grouped together for analysis. Data reviewed included primary admission and readmission costs, reason for readmission, intervention, index and total length of stay, narcotic use, time to ambulation, and time to enteral feeds. RESULTS One hundred eighty-six colectomies were eligible for analysis, with 45 cases (38 primary and 7 secondary) of POI during the index admission. The total cost was significantly higher for patients with POI (

Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program.

16,612 versus

A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics.

8,316; p < 0.05). However, readmission costs were not statistically different for delayed POI and other complications (

Laparoscopic-assisted vs. Open resection - Rectopexy offers excellent results

3,546 versus

Evaluation of transarterial embolization for lower gastrointestinal bleeding

6,705). CONCLUSIONS POI occurred in 24% (84% primary) of colectomy patients and disproportionately affected cost at the index admission. Interestingly, delayed POI was similar in cost to readmission for other serious adverse surgical complications.

Pudendal nerve latency. Does it predict outcome of anal sphincter repair

INTRODUCTION: No consensus exists regarding the optimal fluid (crystalloid or colloid) or strategy (liberal, restricted, or goal directed) for fluid management after colectomy. Prior assessments have used normal saline. This is the first assessment of standard, goal-directed perioperative fluid management with either lactated Ringer’s or hetastarch/lactated Ringer’s, with use of esophageal Doppler for guidance, in laparoscopic colectomy with an enhanced recovery protocol. METHODS: A double-blinded, prospective, randomized, three-armed study with Institutional Review Board approval was used for patients undergoing laparoscopic segmental colectomy assigned to the standard, goal-directed/lactated Ringer’s and goal-directed/hetastarch groups. A standard anesthesia and basal fluid administration protocol was used in addition to the goal-directed strategies guided by esophageal Doppler. RESULTS: Sixty-four patients undergoing laparoscopic colectomy (22 standard, 21 goal-directed/lactated Ringer’s, 21 goal-directed/hetastarch) had similar operative times (standard, 2.3 hours; goal-directed/lactated Ringer’s, 2.5 hours; goal-directed/hetastarch, 2.3 hours). The lactated Ringer’s group received the greatest amount of total and milliliters per kilogram per hour of operative fluid (standard, 2,850/18; goal-directed/lactated Ringer’s, 3,800/23; and goal-directed/hetastarch, 3,300/17; P < 0.05). The hetastarch group had the longest stay (standard, 64.9 hours; goal-directed/lactated Ringer’s, 71.8 hours; goal-directed/hetastarch, 75.5 hours; P < 0.05). The standard group received the greatest amount of fluid during hospitalization (standard, 2.5 ml/kg/h; goal-directed/lactated Ringer’s, 1.9 ml/kg/h; goal-directed/hetastarch, 2.1 ml/kg/h; P < 0.05). There was one instance of operative mortality in the goal-directed/hetastarch group. CONCLUSIONS: Goal-directed fluid management with a colloid/balanced salt solution offers no advantage and is more costly. However, goal-directed, individualized intraoperative fluid management with crystalloid should be evaluated further as a component of enhanced recovery protocols following colectomy because of reduced overall fluid administration.

The management of lower gastrointestinal hemorrhage

Objective:To determine the utility of adding oral nonabsorbable antibiotics to the bowel prep prior to elective colon surgery. Summary Background Data:Bowel preparation prior to colectomy remains controversial. We hypothesized that mechanical bowel preparation with oral antibiotics (compared with without) was associated with lower rates of surgical site infection (SSI). Methods:Twenty-four Michigan hospitals participated in the Michigan Surgical Quality Collaborative–Colectomy Best Practices Project. Standard perioperative data, bowel preparation process measures, and Clostridium difficile colitis outcomes were prospectively collected. Among patients receiving mechanical bowel preparation, a logistic regression model generated a propensity score that allowed us to match cases differing only in whether or not they had received oral antibiotics. Results:Overall, 2011 elective colectomies were performed over 16 months. Mechanical bowel prep without oral antibiotics was administered to 49.6% of patients, whereas 36.4% received a mechanical prep and oral antibiotics. Propensity analysis created 370 paired cases (differing only in receiving oral antibiotics). Patients receiving oral antibiotics were less likely to have any SSI (4.5% vs. 11.8%, P = 0.0001), to have an organ space infection (1.8% vs. 4.2%, P = 0.044) and to have a superficial SSI (2.6% vs. 7.6%, P = 0.001). Patients receiving bowel prep with oral antibiotics were also less likely to have a prolonged ileus (3.9% vs. 8.6%, P = 0.011) and had similar rates of C. difficile colitis (1.3% vs. 1.8%, P = 0.58). Conclusions:Most patients in Michigan receive mechanical bowel preparation prior to elective colectomy. Oral antibiotics may reduce the incidence of SSI.

Treatment of advanced hemorrhoidal disease : a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser

PURPOSE: Anterior resection ± rectopexy effectively manages full-thickness rectal prolapse; however, morbidity is approximately 15 percent mainly because of the laparotomy wound. There has been no comparison of laparoscopic with laparotomy approaches to the repair of this disorder. The purpose of this paper is to compare an age/sex-matched series of laparoscopic-assisted (n=8) with laparotomy (n=10) resections/rectopexies. METHODS: A retrospective case review of laparoscopic-assisted (n=8)vs.laparotomy (n=10) resections/rectopexies from May 1989 to September 1993 was performed. Data collected included age, gender, technique, operative blood loss, operative time, length of bowel resected, length of hospital stay, return of bowel function, oral intake, and postoperative complications. RESULTS: No significant difference was noted in age, sex, length of bowel resected, mortality, significant morbidity, or recurrence (mean follow-up, 27.1 ±4.4 months) in either group. Estimated blood loss for the laparotomy group was greater than for the laparoscopic group (285.0±35.0vs.184.4±31.0 ml). Operative time was greater for the laparoscopic group (177.1±23.0vs.86.5±8.6 min). Length of stay (95.0±16.7vs.183.5±8.9 hours), time to passage of flatus (3.9±1.1vs.2.8±1.9 days), and resumption of oral intake (4.5±0.7vs.2.8±1.9 days) occurred earlier for the laparoscopic group. CONCLUSION: Therefore, laparoscopic-assisted resection/rectopexy effectively treats rectal prolapse without the morbidity of the laparotomy wound and significantly shortens hospitalization for this benign disease.PURPOSE: Anterior resection ± rectopexy effectively manages full‐thickness rectal prolapse; however, morbidity is approximately 15 percent mainly because of the laparotomy wound. There has been no comparison of laparoscopic with laparotomy approaches to the repair of this disorder. The purpose of this paper is to compare an age/sex‐matched series of laparoscopic‐assisted (n=8) with laparotomy (n=10) resections/rectopexies. METHODS: A retrospective case review of laparoscopic‐assisted (n=8) vs. laparotomy (n=10) resections/rectopexies from May 1989 to September 1993 was performed. Data collected included age, gender, technique, operative blood loss, operative time, length of bowel resected, length of hospital stay, return of bowel function, oral intake, and postoperative complications. RESULTS: No significant difference was noted in age, sex, length of bowel resected, mortality, significant morbidity, or recurrence (mean follow‐up, 27.1 ±4.4 months) in either group. Estimated blood loss for the laparotomy group was greater than for the laparoscopic group (285.0±35.0 vs. 184.4±31.0 ml). Operative time was greater for the laparoscopic group (177.1±23.0 vs. 86.5±8.6 min). Length of stay (95.0±16.7 vs. 183.5±8.9 hours), time to passage of flatus (3.9±1.1 vs. 2.8±1.9 days), and resumption of oral intake (4.5±0.7 vs. 2.8±1.9 days) occurred earlier for the laparoscopic group. CONCLUSION: Therefore, laparoscopic‐assisted resection/rectopexy effectively treats rectal prolapse without the morbidity of the laparotomy wound and significantly shortens hospitalization for this benign disease.

Laparoscopic-assistedvs. Open resection

INTRODUCTION: Transcatheter arterial embolization has been used as a therapeutic maneuver for lower gastrointestinal bleeding. The availability of highly selective arteriography has made this procedure safer and warrants re-evaluation. METHODS: A retrospective chart review was done of all patients undergoing arteriography for presumed lower gastrointestinal bleeding at two acute-care community hospitals. Causes of bleeding, clinical outcome, and complications caused by transcatheter arterial embolization were recorded. RESULTS: There were 26 arteriographically identified bleeding sites in the colon and small bowel. The most frequent cause of bleeding was diverticulosis (12 patients), with the diagnosis being arteriovenous malformation in two, and one unknown colonic source. Transcatheter arterial embolization was attempted for 17 separate bleeding episodes in 16 patients. Transfusion requirements were an average (± standard deviation) of 7±1.43 units per patient. Transcatheter arterial embolization was successful in stopping bleeding in 14 cases (82 percent). Two patients had surgery after transcatheter arterial embolization: one for colonic necrosis and one for persisting bleeding. There were two more unsuccessful procedures; one had a successful repeated transcatheter arterial embolization, and one stopped spontaneously. One patient rebled during the same hospitalization and was controlled with intra-arterial vasopressin. There were two deaths, both secondary to sepsis unrelated to the transcatheter arterial embolization or the gastrointestinal tract. CONCLUSIONS: Transcatheter arterial embolization is a relatively safe and successful procedure in patients with massive lower gastrointestinal hemorrhage. It is an excellent choice of therapy for patients that are poor candidates for surgery, but its role in other patients remains to be defined.