Rene F. Hartmann

Colonoscopic bowel preparations—which one?: A blinded, prospective, randomized trial

For the past decade peroral, orthograde, polyethylene glycol-electrolyte lavage solutions (PEG-ELS) have been the preferred bowel-cleansing regimens before diagnostic and therapeutic procedures on the colon and rectum. The large volume and unpalatibility of these solutions may lead to troubling side effects and poor patient compliance. PURPOSE: This study was undertaken to determine which of various colon-cleansing methods before colonoscopy would provide greater patient acceptance while maintaining similar or improved effectiveness and safety. METHODS: Three hundred twenty-nine patients undergoing elective ambulatory colonoscopy were prospectively randomized to one of three bowel preparation regimens. Group 1 received 41 of PEG-ELS (n=124). Group 2, in addition to PEG-ELS, received oral metoclopramide (n=99). Group 3 received oral sodium phosphate (n=106). All groups were evenly matched according to age and sex. RESULTS: Ninety-one percent of all patients completed the preparation received. Sixteen percent of patients suffered significant sleep loss with a bowel preparation. When comparing the three groups, there was no difference in the assessment of nausea, vomiting, abdominal cramps, anal irritation, or quality of the preparation. Compared with other preparations, oral sodium phosphate was better tolerated. More patients completed the preparation (P⩽0.001). Fewer patients complained of abdominal fullness (P⩽0.001). More patients were willing to repeat their preparation (P⩽0.02). Also, sodium phosphate was found to be four times less expensive than either of the PEG-ELS preparations. CONCLUSION: All regimens were found to be equally effective. Abdominal symptoms and bowel preparation were not influenced by the addition of metoclopramide. The oral sodium phosphate preparation was less expensive, better tolerated, and more likely to be completed than either of the other preparations.

Mucosal advancement in the treatment of anal fistula

One hundred eighty-nine patients with anal fistula treated within an eight-month to seven-year period by anal fistulectomy and rectal mucosal advancement are presented. An 80 percent follow-up revealed a 90 percent asymptomatic group and a ten percent group who had minor symptoms. Eight percent of the symptomatic patients had minor soiling; 7 percent were incontinent for gas, and 6 percent were incontinent for loose stools. No patient was incontinent for solid feces. There was a 1.5 percent rate of recurrent anal fistula comparable to other techniques.

Long-term survival after laparoscopic colon resection for cancer: complete five-year follow-up.

AbstractPURPOSE: The role of laparoscopic surgery in the cure of colorectal cancer is controversial. The aim of this study was to evaluate long-term survival after curative, laparoscopic resection of colorectal cancer. Specifically, we wanted to review those patients who now had complete five-year follow-up. METHODS: One hundred two consecutive patients (March 1991 to March 1996) underwent laparoscopic colon resections for cancer at one institution and now have complete five-year survival data. Charts were retrospectively reviewed and results compared with conventional surgery, i.e., open colectomy at our institution, and with the National Cancer Data Base during a similar time period. RESULTS: Fifty-nine male and 43 female patients with an average age of 70 (range, 34–92) years made up the study. Complications occurred in 23 percent of patients, and one patient died (1 percent). Forty-four laparoscopic right colectomies, 2 transverse colectomies, 36 laparoscopic left or sigmoid colectomies, 15 laparoscopic low anterior resections, and 5 laparoscopic abdominoperineal resections were performed. The average number of lymph nodes harvested was 6.6 ± 0.61 (range, 0–22). Eight cases (7.8 percent) were “converted to open”; i.e., the typical 6-cm extraction site was lengthened to complete mobilization, devascularization, resection, or anastomosis, or a separate incision was required to complete the procedure. There was one extraction-site recurrence and one port-site recurrence; both occurred before the routine use of plastic-sleeve wound protection. The mean follow-up for laparoscopic colon resection patients was 64.4 ± 2.8 (range, 1–111) months. According to the TNM classification system, 27 patients had Stage I cancer, 37 had Stage II, 23 had Stage III, and 15 had Stage IV. Similar five-year survival rates for laparoscopic and conventional surgery for cancer were noted. The five-year relative survival rates in the laparoscopic colon resection group were 73 percent for Stage I, 61 percent for Stage II, 55 percent for Stage III, and 0 percent for Stage IV. The five-year relative survival rates for the open colectomy and National Cancer Data Base groups were 75 and 70 percent, respectively, for Stage I, 65 and 60 percent for Stage II, 46 and 44 percent for Stage III, and 11 and 7 percent for Stage IV. CONCLUSIONS: Laparoscopic colon resection for cancer is safe and feasible in a private setting. Our data suggest that long-term survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery. Prospective, randomized trials presently under way will likely confirm these results.

Delayed repair of obstetric injuries of the anorectum and vagina

PURPOSE: We categorized the various types of postobstetric injuries of the anorectum and vagina encountered in a five-year period. The operative procedures used to repair these injuries and the functional outcome after surgery were assessed. METHODS: Between 1986 and 1991, 52 patients were surgically treated for obstetric injuries of the anorectum and vagina; 48 patients were available for follow-up study. Four clinical injury types were identified: Type I, incontinent anal sphincter (11 patients); Type II, rectovaginal fistula (16 patients); Type III, rectovaginal fistula and incontinent anal sphincter (11 patients); and Type IV, cloaca-like defect (10 patients). The mean age of the patients was 30 years, the mean duration of symptoms before surgery was 13 months, and the mean follow-up period was 16 months. The major component of surgical repair for each injury type was: Type I, overlap repair of external anal sphincter; Type II, rectal mucosal advancement flap; Type III, overlap repair of external anal sphincter and rectal mucosal advancement flap; and Type IV, overlap repair of external anal sphincter, anterior levatorplasty, and anal and vaginal mucosal reconstruction. Fecal diversion was not performed in any patient. Specific questions were asked at the most recent follow-up assessment to determine results. RESULTS: Continence status postoperatively was classified as perfect, impaired, or poor; poor was defined as no improvement or worse. Postoperative continence (perfect, impaired, or poor) was, respectively: Type I (11 patients), 64 percent, 36 percent, and 0 percent; Type II (16 patients), 56 percent, 0 percent, and 44 percent; Type III (11 patients), 64 percent, 36 percent, and 0 percent; and Type IV (10 patients), 90 percent, 10 percent, and 0 percent. Vaginal discharge of stool was eliminated in all patients with a rectovaginal fistula. Subjectively, 92 percent of the patients had excellent or good results. Complications included wound hematoma (n=2), fecal impaction (n=2), urinary retention (n=1), and urinary tract infection (n=1). CONCLUSION: Patients with Type II injuries had the worst results (P< 0.001). These patients should be evaluated for anal incontinence before surgery to assess the need for a concomitant sphincteroplasty.

Diverticular disease complicated with colovesical fistula: laparoscopic versus robotic management.

Fistula formation is a complication of diverticulitis in 4% to 20% of cases. The left or sigmoid colon is the most commonly involved segment. The most common presenting symptom is pneumaturia and dysuria, followed by fecaluria, abdominal pain and, rarely, hematuria. Some colovesical fistulas (CVFs) are asymptomatic. CVF is more common in males and in females with a history of hysterectomy. The diagnosis is usually made clinically but can be confirmed by cystoscopy, sigmoidoscopy, barium enema, computed tomography (CT) scan, magnetic resonance imaging (MRI), or virtual colonoscopy. The usual management for symptomatic patients is colon resection, and there is still controversy in the approach to asymptomatic patients. Left colectomy for CVF secondary to diverticular disease can be very challenging owing to the presence of acute and chronic inflammation, which makes the tissues harder and more prone to bleeding. It is also more difficult to visualize and find proper anatomic planes and to identify vital structures. Conversion rates of laparoscopic sigmoidectomy complicated with diverticulitis are double that for cancer and as high as 30%. In general, a colectomy for diverticulitis is considered a more difficult operation than a colectomy for cancer, whether or not a laparoscopic or open approach is chosen. Some authors have proposed laparoscopic surgery as the gold standard approach for diverticular disease and CVF management. The safety of robotic surgery for colorectal diseases has been previously addressed in other studies. The

A new silicone prosthesis in the modified Thiersch operation

Experience with a new silicone prosthesis in the modified Thiersch operation for rectal procidentia in 16 extremely poor-risk patients is presented. The technique of implantation, structural details of the prosthesis, and the clinical results are described. The use of a new silicone prosthesis in the modified Thiersch procedure is a viable alternative in this group of patients. Surgical technique is a primary determining factor in preventing complications.

Urecholine prophylaxis for urinary retention in anorectal surgery

A randomized prospective trial with 108 patients undergoing anorectal surgery was conducted comparing the use of Urecholine® orally or subcutaneously to no treatment controls. There was no difference in postoperative urinary retention rates and caudal or general anesthesia, nor was there an earlier postoperative bowel movement with Urecholine. The volume of intravenous fluids significantly affected retention rates.

Survival after colonic perforation during barium-enema examination

Experience with five patients with perforation of the colon, at the time of barium-enema examination, is presented. Details of management are described. Four of five patients survived while the other survived without sequela of infection until hemiplegia and pneumonia supervened two and 36 days, respectively, postoperatively.

Percutaneous intrahepatic chemotherapy via indwelling portal vein catheter and subcutaneous injection reservoir

Experience with a subcutaneous injection reservoir in patients receiving intraphepatic chemotherapy for metastatic adenocarcinoma to the liver from the colon and rectum is presented. Details of technique are described. It is postulated that the implantable subcutaneous reservoir adds considerably to the quality of life of these patients.

The efficacy of barium-enema examinations in patients with anorectal disease

This retrospective study examines the value of an air contrast barium enema examination in detecting proximal neoplasia in the patient presenting with benign anorectal disease as determined by history, physical examination, rigid, and flexible sigmoidoscopy. In 428 of these patients, the roentgenographic studies showed proximal colonic cancer or polyps in less than 1 percent of patients reviewed. In addition, a review of 402 patients with known colon and rectal cancer were surveyed using the same criteria for diagnosis, and less than 1 percent were misinterpreted as having benign anorectal disease