Oded Zmora

Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial.

ObjectiveTo assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. Summary Background DataMechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. MethodsPatients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. ResultsThree hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. ConclusionsThese results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.

Endorectal advancement flap: are there predictors of failure?

PURPOSE The management of complex perianal fistulas with endorectal advancement flap is aimed at avoiding the risk of sphincter injury associated with traditional surgical methods. Long-term follow-up is required to assess the recurrence and continence outcomes of this procedure. The aim of this study was to review our experience with endorectal advancement flap in the treatment of complex perianal fistulas and to define the predictors of successful healing. METHODS A retrospective chart review of all patients who underwent endorectal advancement flap for complex perianal fistulas between 1988 and 2000 was performed. Follow-up was established by telephone interview. RESULTS One hundred six consecutive endorectal advancement flap procedures were performed on 94 patients (94.4 percent). There were 56 females (59.6 percent). Mean age was 41.6 (range, 18–76) years. Cryptoglandular disease was the most common cause of fistula (n = 41, 43.6 percent), followed by Crohn’s disease (n = 28, 29.8 percent). At a mean follow-up of 40.3 (range, 1–149) months, the procedure was successful in 56 (59.6 percent) of 94 patients. Twelve patients underwent repeat surgery with the same technique because of initial failure, 8 of whom eventually healed. Crohn’s disease was associated with a significantly higher recurrence rate (57.1 percent) when compared with fistulas in patients without Crohn’s disease (33.3 percent, P < 0.04). Prior attempts at repair of the fistula were not associated with less favorable outcome of the procedure (P = 0.5). Recurrence was not associated with the type of fistula, origin, preoperative steroid use, postoperative bowel confinement, use of postoperative antibiotics, or creation of a diverting stoma. The median time to recurrence was 8 (range, 1–156) weeks; there was no postoperative mortality. Two patients had postoperative bleeding, one requiring resuture of the flap on the first postoperative day. Recurrences were observed in 15.7 percent of the patients 3 or more years after the repair. In 8 patients (9 percent), continence deteriorated after the endorectal advancement flap, a more common finding in patients who had undergone previous surgical repairs (P < 0.02). CONCLUSION The success rate of endorectal advancement flap for complex perianal fistulas is modest. Failure is mainly correlated with the presence of Crohn’s disease.

Gracilis Muscle Interposition for the Treatment of Rectourethral, Rectovaginal, and Pouch-vaginal Fistulas : Results in 53 Patients

Background:The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. Material and Methods:A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). Results:Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1–4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohns disease-associated fistulas successfully healed; 75% without Crohns successfully healed. Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1–3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. Conclusion:The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Fibrin Glue Sealing in the Treatment of Perineal Fistulas

AbstractPURPOSE: The surgical management of complex perineal fistulas, such as high transsphincteric and suprasphincteric fistulas, or those associated with Crohn’s disease, radiotherapy, surgical trauma, or cavity or a secondary tract, is associated with the risk of sphincter injury and significant discomfort. Fibrin glue may close fistula tracts without muscle division. Therefore, the aim of this study was to evaluate the use of fibrin glue sealing in treatment of perineal fistulas. METHODS: A retrospective chart review of all patients in whom fibrin glue was used for the treatment of perineal fistula was performed. Patients were contacted by telephone to establish follow-up. RESULTS: Thirty-seven patients underwent injection of fibrin glue for complex perineal fistulas. Twenty-four patients had fibrin glue injection as the principal treatment for the perineal fistula, and 13 had fibrin glue in conjunction with an endorectal advancement flap. The fistula was of cryptoglandular origin in 16 (42 percent) cases and associated with Crohn’s disease and trauma in 7 (19 percent) and 14 (38 percent) patients, respectively. At a mean follow-up of 12.1 months, healing occurred in only 15 (41 percent) patients. The healing rate was 33 percent when fibrin glue was the principal treatment, and 54 percent when used with an endorectal advancement flap. Fistulas of noncryptoglandular origin had a higher success rate, although this difference did not reach statistical significance. There was no morbidity associated with the injection of fibrin glue. CONCLUSION: In this study, fibrin glue had moderate success in the definitive treatment of perineal fistulas. However, 33 percent of the patients in whom fibrin glue was the only treatment used were able to avoid more extensive surgery. Fibrin glue is associated with minimal risk, therefore its application should be considered in patients with complex anal fistulas.

Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia

BackgroundThis study reviewed our experience with laparoscopic ventral postoperative (incisional) hernia repair.MethodsClinical data from the first 100 cases were analyzed retrospectively.ResultsBetween 1997 and 2000, 64 women and 36 men (mean age, 58.4 ± 13.6 years; range, 27–87 years) underwent laparoscopic hernioplasty. Hernias (mean diameter, 6.2 ± 3.7 cm) were in a midline (74%), subcostal (10%), or other incision location, and were recurrent in 25%, of the patients. The mean operative time was 119 ± 77 min. Extensive adhesiolysis was necessary in 37 cases. There was no mortality. The recorded complications included inadvertent enterotomies (n=6), seromas (n=11), prolonged ileus (n=4), and prolonged fever (n=3). Seven cases were converted; to repair accidental enterotomies (n=4) due to difficult adhesiolysis (n=2), or to control bleeding (n=1). Six patients underwent reoperation because of enetric leak (n=3) or bowel obstruction (n=3). There were two documented recurrences (2%). The mean follow-up period was 19 months (range, 12–54 months).ConclusionsLaparoscopic intraperitoneal approach to postoperative ventral (incisional) hernia repair may be associated with significant complications and morbidity, which can be prevented in part by meticulous technique and liberal conversions. The justification of this procedure is the low recurrence rate, according to preliminary results.

Anti-tumor necrosis factor and postoperative complications in Crohn's disease: systematic review and meta-analysis.

Background: Anti‐tumor necrosis factor (TNF) antibodies are efficacious in patients with Crohns disease (CD) but the influence of these medications on surgical outcomes in CD patients has been frequently debated. The aim was to evaluate the impact of preoperative treatment with anti‐TNF antibodies on postoperative complications in CD patients undergoing abdominal surgery. Methods: A systematic review and meta‐analysis of comparative cohort studies was performed assessing postoperative complication rates in CD patients who were treated with anti‐TNF antibodies within 3 months before surgery versus patients who were not. The primary outcome was overall complication rate within 1 month of surgery. Secondary outcomes included the rate of infectious and noninfectious complications. The quality of studies was assessed based on selection of patients and controls, comparability of the study groups, and assessment of outcomes. Odds ratios (OR) with 95% confidence intervals (CIs) were computed. Results: A total of eight studies including 1641 patients were included in our meta‐analysis. Preoperative infliximab therapy in CD patients undergoing abdominal surgery was associated with a trend toward an increased rate of total complications (OR 1.72, 95% CI, 0.93–3.19). Anti‐TNF treatments were associated with a modestly increased risk of infectious complications (OR 1.50, 95% CI 1.08–2.08), mostly remote from the surgical site (OR 2.07 95% CI 1.30–3.30) and with a trend toward a higher rate of noninfectious complications (OR 2.00, 95% CI 0.89–4.46). Conclusion: Preoperative infliximab treatment is associated with an increased risk of postoperative infectious complications, mostly nonlocal. A trend toward an increased risk of noninfectious and overall complications was also observed. (Inflamm Bowel Dis 2012;)

Gracilis Muscle Transposition for Iatrogenic Rectourethral Fistula

ObjectiveTo assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula. Summary Background DataIatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors’ experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula. MethodsA retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions. ResultsEleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients. ConclusionsGracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.

Bowel Preparation Is Associated With Spillage of Bowel Contents in Colorectal Surgery

PURPOSEInfectious complications pose a significant cause of morbidity in colon and rectal surgery. This study was designed to assess the effect of bowel preparation on spillage of bowel contents into the peritoneal cavity during colorectal surgery, and its potential effect on the rate of postoperative infectious complications.METHODSThe quality of bowel preparation and the incidence of spillage of bowel contents were prospectively assessed in patients undergoing elective colon and rectal resection. The patients were followed for 30 days for postoperative infectious and noninfectious complications.RESULTSA total of 333 patients were included in this study, of which 181 did not receive mechanical bowel preparation. Intraoperative spillage of bowel contents occurred in 48 patients (14 percent), whereas in 285 patients (86 percent), spillage did not occur. There was a trend toward a higher rate of overall surgical infectious and noninfectious complications in patients who had spillage of bowel contents compared with patients without spillage; however, this difference was not statistically significant (18.7 vs. 11 percent, and 29 vs. 19 percent, respectively). Preoperative mechanical bowel preparation and colocolonic or colorectal anastomosis was associated with a higher rate of bowel contents spillage, although this difference did not reach statistical significance. Liquid colonic contents caused significantly higher rates of spillage.CONCLUSIONSSpillage of bowel contents into the peritoneal cavity during colon and rectal surgery may increase the rate of postoperative infectious complications. In addition, inadequate mechanical bowel preparation, leading to liquid bowel contents, increases the rate of intraoperative spillage.

Trocar site recurrence in laparoscopic surgery for colorectal cancer

BackgroundLaparoscopic colorectal surgery has been associated with less postoperative pain, an early return of bowel function, a shorter period of hospitalization and disability, and better cosmetic results. However, the application of laparoscopic techniques to the curative resection of colorectal cancer is still controversial, owing to reports of cancer recurrence at the port site wounds. The accumulation of numerous such reports in a relatively short period raised concern that there might be an extraordinary high rate of port site metastases after laparoscopic colorectal surgery. This concern has led to intense clinical and basic research aimed at determining the incidence and causes of wound recurrence and developing preventative measures to address this problem. Despite these efforts, it is still not clear whether port site metastasis is really an inherent drawback to laparoscopic cancer surgery.MethodsIn this review of the literature on port site metastasis, we gathered data from clinical series of laparoscopic surgery for colorectal cancer. We eliminated series of <50 patients, since they may be flawed by the learning curve required for this technically demanding procedure.ResultsThe rate of port site recurrences in the 1737 patients who participated in these series was 1%. Although the methods and criteria for patient selection in these studies varied, this figure appears to be comparable to the incidence reported for other malignancies and for laparotomies performed to treat colorectal cancer.ConclusionThis review suggests that wound recurrence may actually be the result of an unfortunate learning curve, rather than an inherent concern. However, we must await the final results of large randomized studies before drawing any definitive conclusions.

Bowel preparation for colorectal surgery

PURPOSE: The aim of this study was to assess recent literature regarding bowel preparation for colonoscopy and surgery. METHODS: The study was conducted by an Index Medicus English-language search of articles relevant to both oral mechanical and parenteral and oral antibiotic preparation for elective colorectal surgery and mechanical bowel preparation for colonoscopy. The study period was from 1975 to 2000. In addition, studies of elective colorectal surgery without mechanical bowel preparation were also considered. RESULTS: Although several recent prospective, randomized trials have suggested that elective colorectal surgery can be safely performed without any mechanical bowel preparation, mechanical bowel preparation remains the standard of care, at least in North America at the present time. A recent survey of the members of The American Society of Colon and Rectal Surgeons revealed that the majority currently use sodium phosphate for bowel preparation and use a dual oral antibiotic regimen before elective colorectal surgery, combined with two doses of parenteral antibiotics. Although some of the use patterns are based on prospective, randomized study, others seem founded strictly on habit and theory. CONCLUSIONS: The current methods of bowel cleansing for both colonoscopy and surgery include sodium phosphate and polyethylene glycol; colorectal surgeons practicing in North America currently prefer sodium phosphate. Additional preparation for colorectal surgery includes perioperative parenteral antibiotics and, to a slightly lesser degree, preoperative oral antibiotic preparation. Although some recent prospective, randomized studies have suggested that omission of mechanical bowel preparation for elective colorectal surgery is not only feasible but potentially preferable, caution is recommended before routinely omitting these widely practiced measures, because data to support such routine omission are limited.