Massarat Zutshi

Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection.

AbstractINTRODUCTION: In an era of dwindling hospital resources and increasing medical costs, safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare resources. Although several protocols have been reported to reduce postoperative stay, no Level I evidence exists for their use in routine clinical practice. METHODS: Sixty-four patients undergoing laparotomy and intestinal or rectal resection were randomly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care. Time to discharge from hospital, complication and readmission rates, pain level, quality of life, and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery. Subgroups were defined to evaluate those who derived the optimal benefit from the protocol. RESULTS: Pathway patients spent less total time in the hospital after surgery (5.4 vs. 7.1 days; P = 0.02) and less time in the hospital during the primary admission than traditional patients. Patients younger than 70 years old had greater benefits than the overall study group (5 vs. 7.1 days; P = 0.01). Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway (P = 0.01). There was no difference between pathway and traditional patients for readmission or complication rates, pain score, quality of life after surgery, or overall satisfaction with the hospital stay. CONCLUSIONS: Patients scheduled for a laparotomy and major intestinal or rectal resection are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet. Pathway patients have a shorter hospital stay, with no adverse effect on patient satisfaction, pain scores, or complication rates. Patients younger than 70 years of age derive the optimal benefit, and increased surgeon experience improves outcome.

A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.

Introduction:Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer. Aim:To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer. Methods:A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed. Results:Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 ±12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups. Conclusions:In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

Incontinence After a Lateral Internal Sphincterotomy: Are We Underestimating It?

PURPOSEThis study was designed to assess the long-term outcomes and quality of life of patients who have undergone a sphincterotomy for chronic anal fissure.METHODSThe medical records of patients who underwent this operation between 1992 and 2001 were reviewed. A questionnaire was mailed to assess their current status, along with the Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index surveys.RESULTSA total of 298 patients were identified (158 males; 53 percent; mean age, 46.9 years; mean follow-up, 4.3 years). Postal survey response was 62 percent. Recurrence of the fissure occurred in 17 patients (5.6 percent) of whom 9 (52 percent) were females. Significant factors that resulted in recurrence were initial sphincterotomy performed in the office and local anesthesia (P < 0.001). When comparing office records and response to the postal survey, significantly more patients had flatal incontinence than that recorded in their medical records (P < 0.001). Twenty-nine percent of females who had a vaginal delivery recorded problems with incontinence to flatus (P = 0.04). Temporary incontinence was reported in 31 percent of patients and persistent incontinence to gas occurred in 30 percent. Stool incontinence was not a significant finding. The overall quality-of-life scores were in the normal range, whereas the median Fecal Incontinence Severity Index score was 12.CONCLUSIONSRecurrence after lateral internal sphincterotomy may be higher after local anesthesia or office procedure. Females who have two or more previous vaginal deliveries should be warned about possible flatal incontinence. Long-term flatal incontinence that is not reported to the caregiver may occur in up to one-third of patients and could be permanent.

Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer.

PURPOSE: This study was designed to evaluate functional outcome in patients treated with preoperative radiotherapy after low anterior resection and a coloanal anastomosis for low rectal cancer. METHODS: Functional outcome data from patients enrolled in a prospective randomized trial comparing 3 reconstructive procedures were evaluated with respect to administration of preoperative radiotherapy. Incontinence was assessed with a questionnaire on bowel function including the Fecal Incontinence Severity Index; sexual function was assessed with the Sexual Health Inventory for Men and a gender-specific questionnaire for women. Quality of life was assessed with SF-36 scores. RESULTS: Of 364 patients enrolled, 153 (42%) had no radiotherapy or chemotherapy, and 211 (58%) had preoperative radiotherapy; 186 (51%) had chemotherapy in addition to radiotherapy. Comparison of irradiated vs. nonirradiated patients showed no significant differences in postoperative morbidity (29.9% vs. 35.3%; P = 0.27). Two-year follow-up of 297 patients showed greater impairment of bowel function in irradiated patients (n = 170) vs. nonirradiated patients (n = 127): e.g., mean number of daily bowel movements at 12 months, 4.2 ± 3.5 vs. 3.5 ± 2.6, P = 0.032; urgency, 85% vs. 67%, P = 0.002). Antidiarrheal use was significantly higher in irradiated patients vs. nonirradiated patients at 4 (P = 0.043), 12 (P = 0.002), and 24 (P = 0.001) months. Sexual Health Inventory for Men scores indicated poorer function in irradiated patients at 24 months (P = 0.039). Preoperative radiotherapy had no deleterious effects on quality of life. Multivariate analyses showed that negative effects of preoperative radiotherapy on urgency at 4 months (P = 0.002) and antidiarrheal use at 24 months were independent of reconstruction technique, but a positive effect of reconstruction with a J-pouch was still observed in patients who received radiotherapy. CONCLUSION: Preoperative radiotherapy does not increase overall morbidity but is associated with poorer functional outcome after low anterior resection with coloanal anastomosis. Preoperative radiotherapy and the J-pouch are nonconfounding predictors of functional outcome up to 24 months after surgery.

Ten-year outcome after anal sphincter repair for fecal incontinence.

PURPOSE: This study aimed to report at ten years on the results of the same cohort that had been studied at five years who had undergone an anal sphincter repair for fecal incontinence. METHODS: Patients studied at five years were contacted after ten years and asked to fill out the Fecal Incontinence Quality of Life Scale, the Fecal Incontinence Severity Index, and the Bristol Stool Form Scale. RESULTS: Thirty-one of 44 (71 percent) patients were contacted. Median follow-up time was 129 (range, 113 to 208) months. Median age at surgery was 44 (range, 22 to 80) years. No patients were fully continent at 129 months. Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores were correlated with the age at surgery. Older patients had lower Fecal Incontinence Quality of Life scores (P = 0.001), reflecting a lower quality of life, and a higher patient-rated Fecal Incontinence Severity Index score (P = 0.01) and a higher surgeon-rated Fecal Incontinence Severity Index score (P = 0.005), denoting more severe fecal incontinence. The Bristol Stool Form Scale, not utilized at 77 months, showed a correlation to patient-rated Fecal Incontinence Severity Index (P = 0.04) and surgeon-rated Fecal Incontinence Severity Index (P = 0.02). Fecal Incontinence Severity Index scores were significantly higher in women who had more than two vaginal births. CONCLUSION: Continence after overlapping sphincter repair deteriorates in the long term. Long-term outcome was worse for patients who were older at the time of surgery or those with two or more vaginal births. The Bristol Stool Form Scale score correlates with the severity of incontinence, and may be used to guide the management of the patients symptoms.

Quality of life, functional outcome, and complications of coloplasty pouch after low anterior resection.

PURPOSEThe colonic J-pouch has been used to improve bowel function in patients undergoing low colorectal or coloanal anastomosis. However, a narrow pelvis, difficulties in reach, a long anal canal with prominent sphincters, or a fatty mesentery may turn this technique into a technically challenging procedure in certain patients. In these circumstances, “coloplasty” offers an alternative to a straight anastomosis. The purpose of this study was to compare the quality of life, functional outcome, and complications between patients undergoing coloplasty, colonic J-pouch, or straight anastomosis.METHODSAltogether, 162 patients who underwent coloanal or low colorectal anastomosis between 1998 and 2001 were studied. Data collected included demographics, length of follow-up, technique and type of anastomosis, complications, quality of life, and functional outcome. Results were analyzed according to use of a coloplasty (n = 69), colonic J-pouch (n = 43), or straight anastomosis (n = 50). The choice of the technique was based on the surgeon’s preference. Usually coloplasty or straight anastomosis was favored in male patients with a narrow pelvis or when a handsewn anastomosis was used.RESULTSQuality of life assessment with the short form-36 questionnaire revealed better scores in coloplasty and colonic J-pouch groups. The coloplasty (1.0 ± 1.7) and colonic J-pouch (1.0 ± 1.2) groups had fewer night bowel movements than the straight anastomosis group (1.5 ± 2.0) (P < 0.05). The coloplasty group also had fewer bowel movements per day than the straight anastomosis group (3.8 ± 2.9 vs. 4.8 ± 3.6; P < 0.05); also, less clustering and less antidiarrheal medication use were observed than in the straight anastomosis group. Colonic J-pouch patients with handsewn anastomosis had a higher anastomotic leak rate (44 percent) than the patients in the coloplasty with hand-sewn anastomosis group (3.6 percent).CONCLUSIONSColoplasty seems to be a safe, effective technique for improving the outcome of low colorectal or coloanal anastomosis. It is especially applicable when a colonic J-pouch anastomosis is technically difficult.

Anal physiology testing in fecal incontinence: is it of any value?

IntroductionThe prognostic value of postoperative manometry in fecal incontinence is still controversial. The aims of this study were to establish if Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL) scores correlate with anal manometry and endoanal ultrasound findings and to define if there is any prognostic value in performing anal manometry after patients are surgically treated for fecal incontinence.MethodsFifty-three patients, all women, were identified. All patients underwent a surgical procedure and were analyzed pre- and postoperatively. Fecal incontinence was assessed using the FISI and FIQL. Patients who did not have these score were excluded. Manometry and ultrasound findings before treatment and manometry findings after treatment were compared with surgical patient’s incontinence scores. Anal canal length was noted, and its association with the pre- and postoperative manometry finding and incontinence scores were compared.ResultsNo correlation of pre- and postoperative resting and squeeze pressures with incontinence scores was found. Ultrasound findings had no correlation with manometry results and incontinence scores. Anal canal length correlated with both pre- and postoperative manometry findings but not with incontinence scores.ConclusionPreoperative anal manometry and endoanal ultrasound help in guiding treatment options in patients with fecal incontinence. A decrease in FISI and increase in FIQL scores after a sphincter repair quantifies improvement after incontinence surgery, while changes in anal manometry pressures readings do not.

A retrospective review of chronic anal fistulae treated by anal fistulae plug.

Objective  The aim of this study was to analyse the efficacy of the anal fistulae plug (Cook Surgisis® AFP™) for the management of complex anal fistulae.

Effects of sphincterotomy and pudendal nerve transection on the anal sphincter in a rat model

PURPOSE: Our objective was to define anal resting pressure and electromyography of the normal rat anal sphincter and investigate the short-term effects of both mechanical trauma to the anal sphincter muscles and pudendal nerve transection. METHODS: Forty-five virgin female Sprague-Dawley rats were randomly allotted to three groups: controls (n = 21), sphincterotomy (n = 12), and pudendal nerve transection (n = 12). Anal pressure was monitored using a saline-filled balloon connected to a pressure transducer. Anal pressure and electromyography of the anal sphincter with use of a needle electrode were recorded both before and after injury or succinylcholine administration. RESULTS: Anal pressure data were consistent with rhythmic pressure contractions. Succinylcholine significantly reduced both pressure and electromyography signals. Electromyography amplitude and frequency decreased after nerve transection but not after sphincterotomy. The histology showed that the rat anal anatomy has muscular components that compare with human anatomy. The sphincterotomy group showed injury to the anal sphincters and the sphincter anatomy of the nerve transection group appeared similar to the control group. The anal pressure wave appears to be created by synergistic activity of both striated and smooth muscle of the anal sphincter. CONCLUSION: The female rat is a suitable and reliable model for studying effect of direct and indirect injury to the anal sphincters.

Mesenchymal stem cells can improve anal pressures after anal sphincter injury

OBJECTIVE Fecal incontinence reduces the quality of life of many women but has no long-term cure. Research on mesenchymal stem cell (MSC)-based therapies has shown promising results. The primary aim of this study was to evaluate functional recovery after treatment with MSCs in two animal models of anal sphincter injury. METHODS Seventy virgin female rats received a sphincterotomy (SP) to model episiotomy, a pudendal nerve crush (PNC) to model the nerve injuries of childbirth, a sham SP, or a sham PNC. Anal sphincter pressures and electromyography (EMG) were recorded after injury but before treatment and 10 days after injury. Twenty-four hours after injury, each animal received either 0.2 ml saline or 2 million MSCs labelled with green fluorescing protein (GFP) suspended in 0.2 ml saline, either intravenously (IV) into the tail vein or intramuscularly (IM) into the anal sphincter. RESULTS MSCs delivered IV after SP resulted in a significant increase in resting anal sphincter pressure and peak pressure, as well as anal sphincter EMG amplitude and frequency 10 days after injury. MSCs delivered IM after SP resulted in a significant increase in resting anal sphincter pressure and anal sphincter EMG frequency but not amplitude. There was no improvement in anal sphincter pressure or EMG with in animals receiving MSCs after PNC. GFP-labelled cells were not found near the external anal sphincter in MSC-treated animals after SP. CONCLUSION MSC treatment resulted in significant improvement in anal pressures after SP but not after PNC, suggesting that MSCs could be utilized to facilitate recovery after anal sphincter injury.