Stefan Riss

The prevalence of hemorrhoids in adults

IntroductionExact data on the prevalence of hemorrhoids are rare. Therefore, we designed a study to investigate the prevalence of hemorrhoids and associated risk factors in an adult general population.MethodsBetween 2008 and 2009, consecutive patients were included in a prospective study. They attended the Austrian national wide health care program for colorectal cancer screening at four medical institutions. A flexible colonoscopy and detailed examination were conducted in all patients. Hemorrhoids were defined according to a standardized grading system. Independent variables included baseline characteristics, sociodemographic data, and health status. Potential risk factors were calculated by univariate and multivariate analysis.ResultsOf 976 participants, 380 patients (38.93%) suffered from hemorrhoids. In 277 patients (72.89%), hemorrhoids were classified as grade I, in 70 patients (18.42%) as grade II, in 31 patients (8.16%) as grade III, and in 2 patients (0.53%) as grade IV. One hundred seventy patients (44.74%) complained about symptoms associated with hemorrhoids, whereas 210 patients (55.26%) reported no symptoms. In the univariate and multivariate analysis, body mass index (BMI) had a significant effect on the occurrence of hemorrhoids with p = 0.0391 and p = 0.0282, respectively. Even when correcting for other potential risk factors, an increase in the BMI of one increased the risk of hemorrhoids by 3.5%.ConclusionHemorrhoids occur frequently in the adult general population. Notably, a considerable number of people with hemorrhoids do not complain about symptoms. In addition, a high BMI can be regarded as an independent risk factor for hemorrhoids.

The Impact of Thiopurines on the Risk of Surgical Recurrence in Patients With Crohn's Disease After First Intestinal Surgery

OBJECTIVES:Smoking and a lack of immunosuppressive (IS) therapy are considered risk factors for intestinal surgery in Crohns disease (CD). Good evidence for the latter is lacking. The objective of this study was to evaluate the impact of thiopurine treatment on surgical recurrence in patients after first intestinal resection for CD and its possible interaction with smoking.METHODS:Data on 326 patients after first intestinal resection were retrieved retrospectively, and subjects were grouped according to their postoperative exposure to thiopurines. Treatment with either azathioprine (AZA) or 6-mercaptopurine (6-MP) was recorded on 161 patients (49%). Smoking status was assessed by directly contacting the patients.RESULTS:Surgical recurrence occurred in 151/326 (46.3%) patients after a median time of 71 (range 3–265) months. Cox regression revealed a significant reduction of re-operation rate in patients treated with AZA/6-MP for ⩾36 months as compared with patients treated for 3–35 months, for less than 3 months, and to those without postoperative treatment with AZA/6-MP (P=0.004). Cox regression analysis revealed treatment with thiopurines for ⩾36 months (hazard ratio (HR) 0.41; 95% confidence interval (CI) 0.23–0.76, P=0.004) and smoking (HR 1.6; 95% CI 1.14–2.4, P=0.008) as independent predictors for surgical recurrence. Furthermore, longer duration of disease tended to be protective (HR 0.99; 95% CI 0.99–1.0, P=0.067).CONCLUSIONS:Long-term maintenance treatment with AZA/6-MP reduces the risk of surgical recurrence in patients with CD. We also identified smoking as a risk factor for surgical recurrence.

Endo‐sponge assisted treatment of anastomotic leakage following colorectal surgery

Aim  Endo‐sponge assisted treatment (endo‐sponge) represents a novel approach to treat patients with anastomotic dehiscence following anterior resection for rectal cancer. Yet, limited data are available to predict success, compatibility with radiotherapy and/or chemotherapy as well as acceptance by the patients.

Complete cytoreduction for pseudomyxoma peritonei is optimal but maximal tumor debulking may be beneficial in patients in whom complete tumor removal cannot be achieved.

BACKGROUND: Pseudomyxoma peritonei is a diffuse peritoneal malignancy that generally originates form a perforated appendiceal tumor. Optimal treatment requires extensive surgical resection to achieve complete cytoreduction combined with hyperthermic intraperitoneal chemotherapy. In a proportion of patients this is impossible, in particular, owing to extensive irresectable small-bowel involvement. There is ongoing debate as to the role of maximal tumor debulking in such cases. OBJECTIVE:  The aim of this study was to assess the outcomes of patients who underwent major tumor debulking for pseudomyxoma peritonei of appendiceal origin and to compare outcomes with patients who had complete cytoreduction during the same period. DESIGN: This is a retrospective study. SETTINGS: This investigation was conducted at a tertiary referral center for peritoneal surface malignancy. PATIENTS: A prospective database of 953 consecutive patients with peritoneal malignancy undergoing surgery at a UK national referral center between 1994 and 2012 was analyzed. Of these patients, 748 (78%) had surgery for pseudomyxoma peritonei of appendiceal origin. MAIN OUTCOME MEASURES: Survival, morbidity, and mortality in both groups were compared. Univariate and multivariate analyses were performed to identify negative prognostic factors in the group that underwent major tumor debulking. RESULTS: Complete cytoreductive surgery was achieved in 543/748 (73%) patients, and 205 (27%) had maximal tumor debulking. Median age was 56 years (172 (31.7%) men) in the complete cytoreductive surgery group and 59 years (108 (52.7%) men) in the maximal tumor debulking group. Overall survival at 3, 5, and 10 years was 90%, 82%, and 64% in the complete cytoreductive group and 47%, 30%, and 22% in the maximal tumor debulking group. The median survival in the maximal tumor debulking group was 32.8 months (95% CI, 24.1–41.5). LIMITATIONS: The retrospective analysis of prospective data was a limitation of this study. CONCLUSIONS: Maximal tumor debulking may help patients with pseudomyxoma peritonei in whom complete cytoreduction cannot be achieved with almost half alive at 3 years with long-term survival in some.

Repeat intestinal resections increase the risk of recurrence of Crohn's disease.

BACKGROUND: Which factors predict recurrence in patients with Crohn’s disease in the era of immunosuppressive medications is still under debate. OBJECTIVE: The current study was conducted to assess long-term outcome after ileocolic resection for Crohn’s disease and to define predictive factors for surgical relapse. DESIGN: This is a retrospective study. SETTINGS: The study was conducted in a tertiary referral center. PATIENTS: A consecutive cohort of patients (n = 203) with Crohn’s disease who underwent ileocolic resection between 1997 and 2006 were analyzed. The mean follow-up time was 8.4 (±2.4) years. MAIN OUTCOME MEASURES: The cumulative probability for repeated intestinal resection for recurrent Crohn’s disease was described by Kaplan-Meier curves. Predictors of surgical recurrence were analyzed by univariate tests. RESULTS: One hundred five patients (51.7%) were exposed to azathioprine/6-mercaptopurine, and 28 patients (13.8%) were exposed to tumor necrosis factor-&agr; blockers after operation. During the follow-up period, 32 patients (15.8%) were reoperated on for disease recurrence. At 5 and 10 years after index surgery, 95.5% and 81.3% of the patients had reoperation-free survival. Previous resections for Crohn’s disease (HR, 2.981; 95% CI, 1.411–6.29; p = 0.003) and urgent indication for surgery (HR, 2.729; 95% CI, 1.047–7.116; p = 0.03) were significant risk factors for reoperation. In addition, patients with postoperative complications following ileocolonic resection were more likely to require reoperation (HR, 1.712; 95% CI, 041–2.817; p = 0.03). In a multiple Cox regression model, previous intestinal resection for Crohns disease remained significant (p = 0.0114) with a HR of 2.654 (95% CI, 1.246–5.654). LIMITATIONS: The limitation is the retrospective design of the study, with its potential selection bias. CONCLUSION: In the present analysis, previous intestinal resection for Crohns disease was found to be an independent risk factor for surgical recurrence. Consequently, shorter surveillance intervals in this group of patients should be considered.

Peritoneal metastases from colorectal cancer: Patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) is an established treatment modality for patients with pseudomyxoma peritonei. The majority of patients with pseudomyxoma who have complete tumour removal and HIPEC are cured. Over the last decade CRS for peritoneal metastasis of colorectal origin has emerged as an effective treatment strategy in carefully selected patients. Although convincing evidence is limited, available data shows promising results. The key to a successful outcome is appropriate selection of patients. In patients with extensive peritoneal disease, where complete cytoreduction is not achieved, surgical treatment may not be beneficial and might impair quality of life. In this paper we discuss the challenges of selecting patients with colorectal peritoneal metastases who are likely to benefit from CRS with HIPEC.

Short‐term complications of wide‐lumen stapled anastomosis after ileocolic resection for Crohn’s disease: who is at risk?

Aim  There is growing evidence that stapled anastomoses are similarly effective compared to hand‐sewn anastomoses in Crohn’s patients. This study was designed to assess safety and limitations of wide‐lumen stapled ileocolic anastomoses.

Postoperative course and long term follow up after colectomy for slow transit constipation--is surgery an appropriate approach?

Objective  Patients with slow transit constipation who do not respond satisfactorily to common medical treatment are considered candidates for colectomy. The present observational long term study was designed to assess outcome after surgery.

Pelvic organ function and quality of life after anastomotic leakage following rectal cancer surgery

ZusammenfassungEINLEITUNG: Derzeit besteht ein Mangel an Studien, die den Einfluss einer Anastomosendehiszenz nach Rektumkarzinomresektion auf die Beckenbodenfunktion und Lebensqualität untersucht haben. METHODIK: Zwischen 1995 und 2006 wurde an einem Institut bei 500 Patienten mit einem Rektumkarzinom eine Rektumresektion durchgeführt. Sechsunddreißig Patienten (7.2%) entwickelten eine Anastomosendehiszenz nach der Operation. Davon verstarben 15 Patienten (41.6%) in der Nachbeobachtungszeit. Ein standardisierter Fragebogen, welcher den International Index of Erectile Function, Female Sexual Function Index, Short Form-12 Health Survey, International Prostatic Symptom Score, International Consultation on Incontinence Questionnaire-Short Form, Vaizey Incontinence Score und Wexner Constipation Score inkludierte, wurde an alle 21 lebenden Patienten geschickt. Patienten mit einer Rektumkarzinomresektion ohne postoperativer Dehiszenz dienten als Kontrollen für jeden Fall und wurden gematcht nach Geschlecht, Alter (±5), Art der Resektion und neoadjuvanten Therapie (Ja/Nein). ERGEBNIS: Sechzehn Patienten (76.2%) waren verfügbar und wurden in die Analyse einbezogen. Stuhlinkontinenz, Verstopfung und sexuelle Funktion zeigten keinen Unterschied zwischen Patienten und Kontrollgruppe (p = 0,1973, 0,1189, 0,8519). Allerdings war die Harnkontinenz signifikant beeinträchtigt bei jenen Patienten mit Anastomosendehiszenz (p = 0,0430). Die Lebensqualität zeigte keinen signifikanten Unterschied zwischen den beiden Gruppen (p = 1,0000 und 0,1973). ZUSAMMENFASSUNG: Eine Anastomosendehiszenz nach Rektumkarzinomresektion führt zu einer deutlichen Beeinträchtigung der Harnkontinenz. Stuhlinkontinenz, sexuelle Funktion, Verstopfung und Lebensqualität sind vergleichbar zwischen Patienten mit und ohne Anastomosendehiszenz.SummaryINTRODUCTION: There is a paucity of studies assessing the influence of anastomotic leakage after rectal cancer surgery on pelvic organ function and quality of life. METHODS: Between 1995 and 2006, 500 patients underwent rectal resection for malignancies at a single institution. Thirty-six patients (7.2%) developed an anastomotic leakage postoperatively. Fifteen of these patients (41.6%) died during the follow-up period. A self-administering questionnaire including the International Index of Erectile Function, Female Sexual Function Index, Short Form-12 Health Survey, International Prostatic Symptom Score, International Consultation on Incontinence Questionnaire-Short Form, Vaizey Incontinence Score and Wexner Constipation Score was sent to all 21 alive patients. Patients with rectal cancer resection without leakage served as controls for each case and were matched by sex, age (±5 years), type of resection, and neoadjuvant therapy (yes/no). RESULTS: Sixteen patients (76.2%) were available and were included in the analysis. The median follow-up time was 106.8 months (32.4–170.4). Fecal incontinence, constipation, and sexual function did not differ significantly between patients and controls (p = 0.1973, 0.1189, 0.8519, respectively). By contrast, urinary continence was impaired significantly in the leakage group (p = 0.0430) but not in control patients. The Quality of Life assessing Short Form-12 Health Survey reached no significant difference between both groups (p = 1.0000 and 0.1973). CONCLUSION: Anastomotic leakage following anterior resection negatively aggravates urinary function but not fecal incontinence, constipation or sexual functions. The data indicate that patients experiencing anastomotic leakages can be relieved from the fear of gross pelvic floor function disturbances.

Risk of definitive stoma after surgery for peritoneal malignancy in 958 patients: Comparative study between complete cytoreductive surgery and maximal tumor debulking

INTRODUCTION Complete cytoreductive surgery (CRS) can achieve cure or long-term survival in selected patients with peritoneal malignancy. In selected patients, due to extensive disease, complete tumour removal is impossible and optimal strategy may be maximal tumour debulking (MTD). We analysed the stoma related outcome in a series of patients undergoing surgery in a National Peritoneal Malignancy Referral Centre. METHODS All patients who underwent CRS, with or without, intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) between 1994 and 2012 were included. Data was collected prospectively in an institutional database and analysed retrospectively. RESULTS CRS was performed in 958 patients (female: 595, male: 363) of whom 781 (81.5%) had a primary appendix tumour, 63 (6.6%) had a colorectal primary, 47 (4.9%) peritoneal mesothelioma, 38 (4%) an ovarian tumour and 29 patients (3%) other tumours. Complete CRS was achieved in 72% (693/958). Overall 352/958 (37%) had a stoma, which was permanent in 165/958 (17.2%). The median time interval from CRS to reversal of stoma was 4.4 months (range: 1.4-13.8). Stomas were created in 113/265 (42.6%) at MTD (permanent: n = 105 (93%), temporary: n = 8 (7%)), and 239/693 (34.5%) at complete CRS (permanent: n = 60 (25%), temporary: n = 179 (75%)) (p = 0.020). All temporary stomas in the 168/693 (24.4%) of patients who had complete CRS were subsequently reversed. CONCLUSION To achieve complete CRS for peritoneal malignancy a stoma is often required and in a proportion this will be permanent. Overall over one third had a stoma at surgery with almost half subsequently reversed.