S. D. Wexner

A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines.

BackgroundThe aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines.MethodsA prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed.ResultsBetween April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n=1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n= 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and broncho-spasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001).ConclusionsThis large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform “safe” colonoscopies.

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation

An international working party was convened in Rome, Italy on 16–17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so‐called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy

AbstractBackground: The aim of this study was to evaluate disability after laparoscopic colectomy in patients with benign colorectal disease. Methods: Patients who underwent laparoscopic colectomy for benign colorectal diseases were matched with patients who underwent laparotomy for the same diseases by the same surgeons during the same time period. A standardized questionnaire used to assess disability included days until return to partial activity, full activity, and work. Results: Seventy-one patients who underwent laparotomy were compared with 71 patients who underwent laparoscopy. Pathology included 26 patients with adenoma, 23 with Crohns disease, 13 with diverticulitis, and 9 with reversal of Hartmanns procedure in each group. Procedures were partial colectomy with ileocolostomy, colocolostomy, or colorectostomy. There were no significant differences (p > 0.05) in age (55.8 vs. 59.7 years) or in the incidence of perioperative complications (25% vs. 29%) between the laparoscopy and laparotomy groups, respectively. The operative time was longer in the laparoscopic group than in the laparotomy group: 165 versus 122 min (p < 0.001). However, length of hospitalization, return to partial and full activity, and time off of work were significantly shorter in the laparoscopy than in the laparotomy group: 6.3 versus 9.0 days, 2.1 versus 4.4 weeks, 4.2 versus 10.5 weeks and 3.8 versus 7.5 weeks, respectively (p < 0.01 for all). Conclusions: Laparoscopic colectomy for benign colorectal diseases was associated with significantly less disability than was laparotomy in terms of length of hospitalization as well as return to baseline partial and full activity and employment.

How well can surgeons perform colonoscopy

AbstractBackground: Little recent data exist relative to the efficacy or postprocedural complications of surgeons performing diagnostic or therapeutic colonoscopy. Therefore, the aim of this study was to retrospectively assess the outcome of colonoscopy performed by surgeons. Methods: The charts of 2,069 patients who underwent colonoscopy between January 1992 and April 1995 by one of four surgeons at one of two centers were reviewed. Parameters included demographics, indications, procedures and findings, pathology, major complications, length of procedures and dosage of medication. Results: 2,069 colonoscopies were performed for the following indications: 877 polyp surveillance, 509 cancer surveillance, 287 rectal bleeding, 282 family history of colon cancer, 127 change in bowel habits, 112 polyps found by flexible sigmoidoscope or barium enema, 92 inflammatory bowel disease, 48 preoperation, and 58 other indications. Some patients had more than one indication. The cecum could not be intubated in 73 cases (3.5%) due to narrowing and stricture [33] redundancy [18], poor preparation [14], and other miscellaneous conditions [8]. The average procedure time in the 1,023 cases in which it was measured was 34.7 min. Average sedation doses were 2.1 mg of midazolam and 75.2 mg of meperedine in these same cases.The 2,069 colonoscopies included 1,878 biopsies, 353 polypectomies, and 139 other procedures. Some patients had multiple therapeutic interventions. Findings included 2,107 polyps, the pathology of which included 907 tubular; 62 tubulovillous and 41 villous adenomas, 325 hyperplastic polyps, and 68 carcinomas. There were five major complications after polypectomies (0.2%) including two cases of bleeding and three perforations. The two patients with bleeding were admitted to hospital, one for observation for 2 days and the other for colonoscopy, coagulation, and transfusion of 3 units of blood. Of the three patients with perforation, one underwent hospitalization for intravenous antibiotics and the other two for surgery (0.01%). Surgery included one resection with primary closure of the sigmoid perforation and one colostomy. Conclusions: This study confirms the observation that colonoscopy performed by surgeons is safe and rapid whether performed as a therapeutic or as a diagnostic procedure.

Assessment of long-term quality of life after laparoscopic and open surgery for Crohn's disease

Objective  Surgery for Crohns disease (CD) is associated with a high recurrence rate and quality of life (QOL) in these patients is controversial. The aim of this study was to assess QOL in patients after laparoscopic and open surgery for CD by two different validated instruments, a generic nonspecific score and a specific gastrointestinal QOL index.

Surgical resection in Crohn’s disease: is immunosuppressive medication associated with higher postoperative infection rates?

Aim  The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn’s disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

Effects of radiotherapy on different histopathological types of rectal carcinoma

Background  Down staging by pre‐operative chemoradiotherapy is currently considered part of the standard therapeutic approach to rectal carcinoma. The aim of this study was to assess the response to chemoradiotherapy of different histopathological types of rectal carcinoma with emphasis on the mucinous variant.

Topical tacrolimus (FK506) in the treatment of recalcitrant parastomal pyoderma gangrenosum associated with Crohn's disease: report of two cases.

Introduction  Pyoderma gangrenosum is a rare idiopathic skin disorder associated with other diseases, including inflammatory bowel disease. The commonest site is the skin, but sometimes it can occur in the parastomal region. Most of these cases respond to treatment with systemic corticosteroids and cyclosporin or local Kenalog injections.

Quality of life after colectomy for colonic inertia

AbstractBackgroundTotal abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long–term health related quality of life in these patients in relation to their functional outcome.MethodsA consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was healthrelated quality of life assessed at follow–up using the SF–36 Health Survey.ResultsA total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3±27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7±2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF–36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations.ConclusionsAfter TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

Intraoperative endoscopy in laparoscopic colectomy

BackgroundThe localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy.MethodsWe did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon.ResultsBetween 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group (p=0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications.ConclusionIntraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.