Norma Daniel

Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy bowel cleansing methods

PURPOSE: Recent reports have suggested that precolonoscopy bowel preparation is easier to tolerate if a small volume solution is used. Therefore, the aim of this study was to compare three oral solutions for colonoscopy to determine any changes in either patient compliance or cleansing ability. METHODS: Four hundred fifty patients were prospectively randomized to receive either a standard 4-liter polyethylene glycol solution, a newer sulfatefree 4-liter polyethylene giycol solution, or a 90-ml oral sodium phosphate preparation. Before and after bowel preparation all patients were weighed, and serum electrolytes as well as phosphate, magnesium, calcium, and osmolarity were measured. In addition, a detailed questionnaire was used to assess side effects and patient satisfaction. Endoscopists blinded to the type and quantity of preparation used scored the type of residual stool and the percentage of bowel wall visualized for each segment of colon and for the overall examination. Nurses recorded all procedure times as well as the quantity of irrigation and aspiration. RESULTS: Four hundred twenty-two agematched and sex-matched patients completed all phases of the trial. There were no clinically significant changes in weight or in any biochemical parameters. There was, however, asymptomatic hyperphosphatemia in the sodium phosphate group (P<0.01).The length of time to the cecum was similar for all three groups, with a higher volume of fluid suctioned for sodium phosphate (P< 0.01).Overall, endoscopists scored sodium phosphate as “excellent” or “good” in 90 percentvs.70 percent and 73 percent after the polyethylene glycol or sulfate-free lavage, respectively (P<0.01). Paniculate or solid stool was found in all segments of the colon more frequently after both large volume preparations than after sodium phosphate (P<0.05). There were no significant differences in the frequency or intensity of any of the 11 side effects questioned. Eighty-three percent of the patients who received the sodium phosphate preparation stated they would take this same preparation again,vs.only 19 percent and 33 percent for polyethylene glycol and the sulfate-free lavage, respectively (P<0.01). CONCLUSION: The smaller volume oral sodium phosphate was not associated with any clinically significant problem, caused no increase in the incidence of side effects, was preferred by patients, and was more effective in colonic cleansing. However, the hyperphosphatemia seen may limit its use in patients with impaired renal function.

Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions.

AIM: The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery. METHODS: All eligible patients were prospectively randomized to receive either 4 1 of standard polyethylene glycol (PEG) solution or 90 ml of sodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxons rank-sum test and Fishers exact test. RESULTS: Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaP solutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P<0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17vs.32 percent;P<0.0002), less abdominal pain (12vs.22 percent;P=0.004), less bloating (7vs.28 percent), and less fatigue (8vs.17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P<0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P<0.0001). For quality of cleansing, surgeons scored NaP as “excellent” or “good” in 87 compared with 76 percent after PEG (P=not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P=not significant). CONCLUSION: Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Colectomy for constipation: Physiologic investigation is the key to success

The results of total abdominal colectomy (TAC) with ileorectal anastomosis as a treatment for colonic inertia (CI) were prospectively assessed. One hundred sixtythree patients were evaluated for chronic constipation between July 1988 and November 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence of puborectalis contraction on CD or EMG. Sixteen patients (10 percent; 15 females and 1 male) with a mean age of 45 years (range, 24–75 years) with CI underwent TAC. Preoperative bowel frequency ranged from three per week to one per month; all 16 patients evacuated only with high doses of laxatives, enemas, or both. TAC was performed with no postoperative mortality or major morbidity; three patients were readmitted four times for successful conservative treatment of partial small bowel obstruction. At a mean followup of 15 months (range, 2–35 months), these 16 patients reported a mean frequency of spontaneous bowel evacuations of 3.5 per day (range, one to six per day). Patient satisfaction with the operation was “excellent” or “good” in 15 cases (94 percent). Thorough preoperative physiologic evaluation permits the selection of a small group of patients with CI who may benefit tremendously from TAC.

Loop ileostomy is a safe option for fecal diversion

This study was undertaken to prospectively assess all morbidity and mortality associated with temporary loop ileostomy. Eighty-three consecutive patients of a median age of 45 years required temporary fecal diversion after either ileoanal or low colorectal anastomosis (n=72), for perianal Crohns disease (n=5), or for other reasons (n=6). All loop ileostomies were supported with a rod, and fecal diversion was maintained for a mean of 10 weeks. To date, 67 patients have had re-establishment of intestinal continuity. Stoma closure was affected through a parastomal incision in 64 patients; in three, a laparotomy was required. The closure was stapled side to side in 49 patients, while a hand-sewn anastomosis was done in the other 18 patients; all skin wounds were left open. The mean length of surgery for ileostomy closure was 56 minutes, and the mean hospital stay was five days. Nine patients (10.8 percent) developed 10 complications, nine of which required hospitalization. Specifically, four patients developed dehydration and electrolyte abnormalities secondary to high stoma output, and two had anastomotic leaks that spontaneously healed following conservative management. One patient developed a superficial wound infection that spontaneously drained itself. One patient developed a partial small bowel obstruction that resolved without surgery after a four-day hospitalization. One stoma retracted after supporting rod removal and prompted premature closure. There was no stomal ischemia, hemorrhage, prolapse, or mortality in this series. Thus, loop ileostomy is a safe way to achieve fecal diversion.

Perineal rectosigmoidectomy in the elderly

Between April 1989 and October 1991, 20 consecutive patients underwent perineal rectosigmoidectomy and coloanal anastomosis for full-thickness rectal prolapse. These 16 females and 4 males, with a mean age of 82 (range, 68–101) years, were evaluated by detailed functional assessment and physiologic testing. A grading scale from 0 to 24 was based upon the frequency and type of incontinence, 0 representing full continence. The mean preoperative continence score was 14.5, while the mean postoperative continence score was 8.4. The mean length of resected rectosigmoid was 23 cm. There was one postoperative death and one significant complication, a postoperative pelvic hematoma that required reoperation. There were no full-thickness recurrences at a mean follow-up of 26 months. Six of the 10 patients who underwent preoperative pudendal nerve terminal motor latency (PNTML) testing had evidence of severe neuropathy (latencies greater than 2.5 milliseconds). Prolonged PNTML, however, was not shown to be an accurate predictor of postoperative incontinence because four of the six patients with neuropathy regained excellent to good control. In conclusion, perineal rectosigmoidectomy is a safe operation for the treatment of full-thickness rectal prolapse in the elderly patient. Improved postoperative continence was noted in 90 percent of patients, with improvement seen even in those patients with severe pudendal neuropathy.

Is bowel confinement necessary after anorectal reconstructive surgery? A prospective, randomized, surgeon-blinded trial.

PURPOSE: The aim of this study was to assess any differences between the inclusion or omission of medical bowel confinement relative to postoperative morbidity and patient tolerance after anorectal reconstructive surgery. METHODS: Between January 1995 and February 1997 a prospective randomized trial was conducted for patients without stomas who underwent anorectal reconstructive surgery. All patients were randomly assigned either to medical bowel confinement (a clear liquid diet with loperamide 4 mg by mouth three times per day and codeine phosphate 30 mg by mouth four times per day until the third postoperative day) or to a regular diet, beginning the day of surgery. All patients in both groups underwent the identical preoperative oral mechanical preparation, preoperative oral and parenteral antibiotics, and postoperative antibiotics. Wound closure and wound care were identical in both groups. RESULTS: Fifty-four patients (46 females) were prospectively, randomly assigned to medical bowel confinement (n=27; 50 percent) or a regular diet (n=27; 50 percent); the mean ages were 51.0 (range, 28–80) and 47.2 (range, 23–87) years, respectively. Indications for surgery were fecal incontinence in 32 patients, complicated fistulas in 17 patients, anal stenosis in 4 patients, a Whitehead deformity in 1 patient, and a chronic unhealed fissure in 1 patient. Fifty-four patients underwent 55 procedures: 32 patients underwent sphincteroplasty, 18 patients underwent transanal advancement flaps, and 5 patients underwent anoplasties. There were no differences between the two groups in the incidence of either septic or urologic complications. Nausea and vomiting were recorded in seven (26 percent) medical bowel confinement and three (11 percent) regular-diet patients. The first postoperative bowel movement occurred at a mean of 3.9 days in the medical bowel confinement group and 2.8 days in the regular diet group (P<0.05). Fecal impaction occurred in seven (26 percent) of the patients in the medical bowel confinement group and two (7 percent) of the patients in the regular diet group. Hospital charges analysis showed a mean cost of hospitalization of

The effect of colorectal surgery in female sexual function, body image, self-esteem and general health: a prospective study.

12,586.00 (range,

The Efficacy of a Nerve Stimulator (Cavermap®) to Enhance Autonomic Nerve Identification and Confirm Nerve Preservation During Total Mesorectal Excision

3,436.00−

Erratum: The efficacy of a nerve stimulator (Cavermap®) to enhance autonomic nerve identification and confirm nerve preservation during total mesorectal excision (Diseases of the Colon and Rectum (December 2004) 47:12 (2032-2038) DOI: 10.1007/s10350-004-0718-5)

20,375.00) for the medical bowel confinement group and

Efficiency and productivity of a sheathed fiberoptic sigmoidoscope compared with a conventional sigmoidoscope

10,685.00 (range,