Peter Buchmann

A multivariate analysis of potential risk factors for intra- and postoperative complications in 1316 elective laparoscopic colorectal procedures.

Objective:To identify predictive risk factors for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery. Background Data:In emergency situations or in elective open and laparoscopic colorectal surgery, there are many risk factors that should be recognized by the surgeon to reduce complications and initiate adequate treatment. Most available data, thus far, refer to open colorectal surgery and literature that focuses mainly on a laparoscopic approach is still rare. Methods:Univariate and multivariate analyses of a prospectively gathered database (1993–2006) were performed on a consecutive series of patients (1316) undergoing laparoscopic colorectal surgery who were operated at a single institution (first referral center). Patients were assessed for demographic data, operative indications, type of resection, and intra- and postoperative complications. Altogether, we analyzed 20 potential risk factors to identify significant influence on the intra- and postoperative outcome. Results:Significant risk factors that led to intraoperative complications consisted of age ≥75 years and malignant neoplasia. Increased postoperative rate of surgical complications was significantly influenced by male gender, age ≥75 years, American Society of Anesthesiology class ≥III, malignant neoplasia, and the experience of the surgeon. The analysis of specific medical postoperative complications revealed even more significant predictive risk factors. In addition, our analysis showed that specific risk factors predict specific complications such as postoperative bleeding, anastomotic leakage, and surgical site infections. The type of surgical procedure performed also influenced patient outcome. Conclusion:This large single center study provides the first evidence of the significance of predictive risk factors for intra- and postoperative complications in laparoscopic colorectal surgery.

HPV 16-positive bowenoid papulosis and squamous-cell carcinoma of the anus in an HIV-positive man

A homosexual man in stage IV of HIV infection, who suffers from HPV 16-positive bowenoid papulosis of the anal region, is described. In one area the patient developed an HPV 16-positive squamous-cell carcinoma of the anus. Bowenoid papulosis represents a squamous-cell carcinomain situ, and usually follows a benign clinical course. The possibility exists that immunocompromised individuals are at higher risk to develop cancer on the basis of bowenoid papulosis.

Treatment of distal ulcerative colitis with beclomethasone enemas: High therapeutic efficacy without endocrine side effects

Sixteen patients with 18 attacks of distal ulcerative colitis were treated randomly with either 0.5 mg topically administered beclomethasone dipropionate (BDP) or 5 mg betamethasone phosphate (BMT). The effect of the steroid enemas on adrenocortical function was examined by ACTH tests, which were performed before and 20 days after treatment. At completion of the trial, a marked suppression of the adrenocortical function was found in seven of eight patients treated for nine attacks with BMT but not in any patients in the BDP group (P<0.01). The mean posttreatment basal and stimulated plasma cortisol levels in the BMT group were significantly lower as compared with the BDP group. The overall therapeutic response assessed by score systems was comparable in the two treatment groups. It is concluded that, in the topical treatment of ulcerative colitis, BDP is preferable to BMT because it exerts an equal anti-inflammatory action without affecting adrenocortical function.

Endoscopic follow‐up after colorectal cancer surgery. Early detection of local recurrence?

This study deals with 188 consecutive patients who had a radically resected colorectal carcinoma and who were later controlled by colonoscopy. The median interval between resection and endoscopy was 2.5 (0.5–19) years. In 20 patients, a local recurrence was found (10.6%). In 11 of these 20 patients the indication for colonoscopy was the clinical suspicion of a recurrence. The remaining nine patients were asymptomatic, and colonoscopy was done as a routine procedure. In six of nine asymptomatic patients, a potentially curative resection of the recurrent tumor was possible, which was not possible in any of the 11 symptomatic patients. Nineteen of the 20 patients with a local recurrence could be followed up. Five of the six patients with potentially curative resection of the recurrence were asymptomatic for a median time of 38 (12–72) months after surgery; in contrast, 9 of 13 patients without curative operation died after a median survival period of 8 (1–24) months. The results of this study suggest that good long‐term prognosis may be expected in patients in whom local recurrence is detected at an early asymptomatic stage with the possibility of potentially curative resection. Therefore, the authors propose regular endoscopic examinations in the first years after curative colorectal cancer surgery.

Rubber band ligation for piles can be disastrous in HIV-positive patients.

We report a patient with haemorrhoids treated with rubber band ligation who developed a huge supralevator abscess. A diverting sigmoidostomy had to be established as surgical drainage via the rectum was not adequate. Eventually the patient accepted the HIV-testing which proved positive. Six months later the sigmoidostomy was still needed as the abscess cavity remained large. We conclude that rubber band ligation in HIV-positive patients should be abandoned.

Fibrosis of experimental colonic anastomosis in dogs after EEA stapling or suturing.

Two out of five patients with a colonic anastomosis stapled with the EEA device, under protection of a diverting colostomy, developed stenosis requiring reoperation. Therefore, a canine experiment was conducted in order to compare the degree of fibrosis in a sutured with that in a stapled anastomosis. A colonic loop excluded from the fecal stream was transsected twice. One anastomosis was done by sutures, the other by an EEA stapling device. The amount of fibrous tissue between the circular muscle layer and the lamina muscularis mucosae was measured on strips of 2-mm length. Immediately after surgery, the submucosal edema was similar in both anastomoses. Marked fibrous thickening of stapled anastomoses developed after two to six months. In contrast, sutured anastomoses elicited very little fibrous thickening of the lamina submucosa. This difference in fibrosis could not be demonstrated following use of the stapling device alone,i.e., without staples. The fibrous thickening, measured in a stapled anastomosis diverted from the fecal stream, exceeds that seen in a sutured anastomosis and may result in stenosis. Therefore, it is suggested that an anastomosis, protected by a diverting colostomy, should be sutured.

Stenosis of the large intestine complicating scleroderma and mimicking a sigmoid carcinoma

An unusual case of scleroderma with colonic involvement mimicking sigmoid carcinoma is presented. Severe low colonic obstruction was due to stenosis of the large intestine making segmental colonic resection mandatory

Predictors of intra- and postoperative complications in laparoscopic colorectal surgery: results of an expert survey.

Background: The decision which patient should undergo laparoscopic rather than open colorectal surgery depends on weighing its benefits against its complications. We explored which criteria prognosticate complications in a laparoscopic intervention by assembling experienced visceral surgeons’ beliefs. Methods: A two-round postal survey was conducted: 21 experts in laparoscopic surgery were contacted and asked to list (first round) and weigh (second round) indicators (scale 1–10) they believed predicted intra- or postoperative complications in patients undergoing laparoscopic colorectal surgery. Median ratings and interquartile ranges (IQRs) were calculated. Rates ≧6 and IQRs ≤3 depicted an important prognostic indicator for complications. Results: Thirty-nine intraoperative and 43 postoperative listings and ratings of 19 experts (90%) were available for analysis. The experts depicted three domains of indicators (tumor, comorbidity and related institution). The strongest indicators for intraoperative complications were surgeon’s experience (median 9, IQR 8–10) and portal hypertension (median 9, IQR 7–10), and those for postoperative complications were liver cirrhosis Child B/C (median 8, IQR 7.75–10) and experience of the surgeon (median 8, IQR 7–10). Conclusion: This survey provides additional evidence of risk indicators for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery. Whether the identified indicators can be compiled into a prognostic instrument requires confirmation in a properly designed and sized study.

A sigmoidoscope to facilitate reanastomosis following a hartmann procedure

The use of a sigmoidoscope to introduce the circular stapler is described. This technique facilitates reanastomosis following a Hartmann procedure.