Stephen M. Cohen

Is early oral feeding safe after elective colorectal surgery ? A prospective randomized trial

IntroductionThe routine use of a nasogastric tube after elective colorectal surgery is no longer mandatory. More recently, early feeding after laparoscopic colectomy has been shown to be safe and well tolerated. Therefore, the aim of our study was to prospectively assess the safety and tolerability of early oral feeding after elective “open” abdominal colorectal operations. Materials and MethodsAll patients who underwent elective laparotomy with either colon or small bowel resection between November 1992 and April 1994 were prospectively randomized to one of the following two groups: group 1: early oral feeding–all patients received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated; group 2: regular feeding–all patients were treated in the “traditional” way, with feeding only after the resolution of their postoperative ileus. The nasogastric tube was removed from all patients in both groups immediately after surgery. The patients were monitored for vomiting, bowel movements, nasogastric tube reinsertion, time of regular diet consumption, complications, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 mL occurred in the absence of bowel movement. Ileus was considered resolved after a bowel movement in the absence of abdominal distention or vomiting. ResultsOne hundred sixty-one consecutive patients were studied, 80 patients in group 1 (34 maies and 46 females, mean age 51 years [range 16–82 years]), and 81 patients in group 2 (43 males and 38 females, mean age 56 years [range 20–90 years]). Sixty-three patients (79%) in the early feeding group tolerated the early feeding schedule and were advanced to regular diet within the next 24 to 48 hours. There were no significant differences between the early and regular feeding groups in the rate of vomiting (21% vs. 14%), nasogastric tube reinsertion (11% vs. 10%), length of lieus (3.8 ± 0.1 days vs. 4.1 ± 0.1 days), length of hospitalization (6.2 ± 0.2 days vs. 6.8 ± 0.2 days), or overall complications (7.5% vs. 6.1%), respectively, (p = NS for all). However, the patients in the early feeding group tolerated a regular diet significantly earlier than did the patients in the regular feeding group (2.6 ± 0.1 days vs. 5 ± 0.1 days; p < 0.001). ConclusionEarly oral feeding after elective colorectal surgery is safe and can be tolerated by the majority of patients. Thus, it may become a routine feature of postoperative management in these patients.

Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy bowel cleansing methods

PURPOSE: Recent reports have suggested that precolonoscopy bowel preparation is easier to tolerate if a small volume solution is used. Therefore, the aim of this study was to compare three oral solutions for colonoscopy to determine any changes in either patient compliance or cleansing ability. METHODS: Four hundred fifty patients were prospectively randomized to receive either a standard 4-liter polyethylene glycol solution, a newer sulfatefree 4-liter polyethylene giycol solution, or a 90-ml oral sodium phosphate preparation. Before and after bowel preparation all patients were weighed, and serum electrolytes as well as phosphate, magnesium, calcium, and osmolarity were measured. In addition, a detailed questionnaire was used to assess side effects and patient satisfaction. Endoscopists blinded to the type and quantity of preparation used scored the type of residual stool and the percentage of bowel wall visualized for each segment of colon and for the overall examination. Nurses recorded all procedure times as well as the quantity of irrigation and aspiration. RESULTS: Four hundred twenty-two agematched and sex-matched patients completed all phases of the trial. There were no clinically significant changes in weight or in any biochemical parameters. There was, however, asymptomatic hyperphosphatemia in the sodium phosphate group (P<0.01).The length of time to the cecum was similar for all three groups, with a higher volume of fluid suctioned for sodium phosphate (P< 0.01).Overall, endoscopists scored sodium phosphate as “excellent” or “good” in 90 percentvs.70 percent and 73 percent after the polyethylene glycol or sulfate-free lavage, respectively (P<0.01). Paniculate or solid stool was found in all segments of the colon more frequently after both large volume preparations than after sodium phosphate (P<0.05). There were no significant differences in the frequency or intensity of any of the 11 side effects questioned. Eighty-three percent of the patients who received the sodium phosphate preparation stated they would take this same preparation again,vs.only 19 percent and 33 percent for polyethylene glycol and the sulfate-free lavage, respectively (P<0.01). CONCLUSION: The smaller volume oral sodium phosphate was not associated with any clinically significant problem, caused no increase in the incidence of side effects, was preferred by patients, and was more effective in colonic cleansing. However, the hyperphosphatemia seen may limit its use in patients with impaired renal function.

Laparoscopic colorectal surgery--are we being honest with our patients?

PURPOSE: A survey was undertaken to assess the impact of laparoscopy on the practice of colorectal surgery. METHODS: A total of 1,520 questionnaires were mailed to all members of the American Society of Colon and Rectal Surgeons; 635 (42 percent) surgeons responded, 50 percent, and indicated that one questionnaire represented their entire group practice. RESULTS: Two hundred seventy-eight (47 percent) respondents currently perform laparoscopic colorectal surgery; 62 percent (171) use the laparoscope for ≤20 percent of their bowel resections. Conversely, only 6 percent (16) use the laparoscope in over 50 percent of resections. The percentage of surgeons who perform various procedures were right colectomy, 78 percent; left colectomy, 57 percent; stoma creations, 52 percent; anterior resection, 44 percent; Hartmanns closure, 42 percent; abdominoperineal resection, 27 percent; rectopexy, 18 percent; and total colectomy, 14 percent. If the preoperative diagnosis is known to be carcinoma, 196 (71 percent) surgeons attempted laparoscopic colorectal surgery, but 55 percent of surgeons (108) operated only for early lesions and 35 percent (68) only for palliation. To enable the procedure to be laparoscopically performed, 87 percent (243) of surgeons stated that they have changed their practice to include routine use of ureteral stents (23 percent), preoperative colonoscopic marking of small lesions (40 percent), or intraoperative colonoscopy. Despite increased use of endoscopy, there were 18 patients in whom the wrong segment of colon was removed. Moreover, nine patients had early local recurrence after resection of colon cancer, nine had early local recurrence after rectal cancer resection, and five had early port-site recurrence. Although 255 (40 percent) surgeons surveyed would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 38 (6 percent) would have a laparoscopic anterior resection for cancer. CONCLUSIONS: Several important problems exist including early port-site recurrence and a dual surgical standard. Although many surgeons are eager to practice laparoscopic colorectal surgery on their patients with carcinoma, they are reluctant to have the new technique applied to themselves.

Must early postoperative oral intake be limited to laparoscopy

PURPOSE: This prospective, randomized study was designed to evaluate whether or not early postoperative feeding (claimed as a unique benefit of laparoscopic surgery) is possible after laparotomy and colorectal resection. METHODS: The trial was performed between July 1, 1992 and October 31, 1992 and included all 64 consecutive patients who underwent laparotomy with either a colonic or an ileal resection. In all cases the nasogastric tube was removed immediately after the operation. Group 1 consisted of 32 patients (age range, 15–81 years; mean, 52 years) who received a regular diet on the first postoperative morning. Group 2 consisted of 32 patients (age range, 15–87 years; mean, 52 years) who were fed in a traditional manner. Regular food was permitted after resolution of ileus as defined by resumption of bowel movements in the absence of abdominal distention, nausea, or vomiting. RESULTS: The rate of nasogastric tube reinsertion for distention with persistent vomiting was 18.7 percent (six patients) in Group 1 and 12.5 percent (four patients) in Group 2. Although vomiting was experienced more frequently by patients in Group 1 (44 percentvs.25 percent, respectively), there was no difference between the two groups with regard to the duration of postoperative ileus (3.6vs.3.4 days, respectively). In the 26 patients from Group 1 who did not require nasogastric tube reinsertion, there was a trend toward shorter hospitalization (6.7vs.8.0 days, respectively). CONCLUSION: Early oral intake is possible after laparotomy and colorectal resection. Thus, the laparoscopic surgeons claim of early tolerated oral intake may not be unique to laparoscopy.

Laparoscopic Colorectal Surgery: Ascending the Learning Curve

Abstract. The aim of this study was to prospectively assess the results of our first 100 consecutive patients who underwent laparoscopic or laparoscopy-assisted colorectal operations. The parameters studied included the type and length of procedure, intra- and postoperative complications, conversion to open surgery, length of ileus, and hospitalization. A total of 100 laparosopic and laparoscopy-assisted procedures were performed between May 1991 and April 1994. The mean patient age was 49 years (12–88 years). The procedures included 36 total abdominal colectomies (TACs) (ileoanal reservoir 28, ileorectal anastomosis 6, end-ileostomy 2), 39 segmental resections of the colon and small bowel, 8 resections of the rectum, 7 diverting stoma creations, 7 reversals of Hartmann’s procedure, and 3 other procedures. In seven cases (7%) the laparoscopic procedure was converted to a laparotomy. A group of 22 patients sustained 26 complications that included enterostomy (n = 5), hemorrhage (n = 6), intraabdominal abscess (n = 4), prolonged ileus (n = 4), wound infection (n = 2), anastomotic leak (n = 1), aspiration (n = 1), cardiac arrhythmia (n = 1), upper intestinal bleeding (n = 1), and postoperative small bowel obstruction (n = 1). There were no deaths. When divided into three equal, consecutive groups, the patients in the early (n = 33) and intermediate (n = 33) groups had a significantly higher complication rate (42% and 27%, respectively), than those in the late group (n = 34, 12%;p < 0.05). The complication rate in each group was also directly related to the number of TACs performed (18 in the early, 13 in the intermediate, and 5 in the late group). The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 9%, nonresectional 12%;p < 0.01). The mean operating time was 4 hours (2.5–6.5 hours) for TAC, 2.5 hours (1.5–5.5 hours) for segmental colonic resection, and 1.6 hours (1.0–2.5 hours) for the nonresectional procedures. The length of ileus was 3.5 days (2–7 days) after TAC, 3 days (2–7 days) after the segmental resections, and 2 days (1–4 days) after the nonresectional procedures. The mean hospital stay was 7.3 days (2–40 days): 8.4 (5–40), 7.0 (4–12), and 6.8 (2–11) days for the TAC, segmental resection, and nonresectional procedures, respectively. We conclude that the feasibility of laparoscopic colorectal surgery has been well established. The morbidity associated with laparoscopic colorectal surgery correlates with a steep learning curve but is also related to the type of procedure. TAC is associated with a higher complication rate than are other laparoscopic colorectal procedures.

A Human Colorectal Explant Culture to Evaluate Topical Microbicides for the Prevention of HIV Infection

A human colorectal explant culture was developed to assess the safety and efficacy of topical microbicides proposed for use in humans. Because any product marketed for vaginal application will likely be used for anal intercourse, it is important to evaluate these products in colorectal explant tissue. Microbicides tested included cellulose acetate 1,2-benzenedicarboxylate (CAP), PRO 2000, SPL7013, Vena Gel, and UC781, along with their accompanying placebos. Colorectal tissues were exposed to microbicides overnight and either fixed in formalin to evaluate toxicity by histological analysis or placed in 1-(4,5-dimethylthiazol-2-yl)-3,5-diphenylformazan (MTT) to quantitatively determine tissue viability. Histological analysis showed minimal toxicity for CAP, UC781, and Vena Gel. Shedding of epithelium with intact lamina propria occurred for the PRO 2000 and SPL7013 products, and shedding of epithelium and necrosis of the lamina propria occurred in explants cultured with nonoxynol-9. The MTT assay confirmed these results for PRO 2000 (4% and 0.5%), SPL7013 (and placebo), and nonoxynol-9 but also demonstrated reduced viability for CAP. However, viability of tissues treated with all products was not significantly different from that of the medium control. Efficacy of the microbicides was evaluated by measuring human immunodeficiency virus type 1 (HIV-1) infection of explants in the absence or presence of products. All microbicide formulations tested were highly effective in preventing HIV infection. However, explants treated with some of the placebo formulations also exhibited a lower level of infection. Most of the products developed for vaginal application showed minimal toxicity and were effective in reducing HIV-1 infection in colorectal tissues. These results suggest that this model is useful for evaluating the safety and efficacy of topical microbicides when used rectally.

Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

AbstractBackgroundAdhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm®) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the lenght of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.MethodsTwenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.ResultsAll 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p=0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p=0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p=0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).ConclusionsWhen consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Laparoscopic colorectal resection for cancer: the Cleveland Clinic Florida experience.

Since the first successful laparoscopic cholecystectomy was performed in 1987, surgeons have begun to focus their attention on more diverse procedures. The last few years have brought a tremendous amount of enthusiasm toward laparoscopic surgery, which has finally reached the colorectal surgical communities. Currently, laparoscopic bowel surgery is undergoing critical appraisal. Through meaningful prospective data retrieval, answers are being obtained to questions dealing with the efficacy and utility of this technique for colorectal diseases. Specifically, although laparoscopic colorectal surgery is feasible, one cannot definitively attest to its superiority or even equivalence to standard open laparotomy. Furthermore, it will take 5 years before we begin to collect data regarding survival rates and local recurrence for the patient with colorectal carcinoma. This article discusses the technique utilized, and our own experience with laparoscopic colorectal surgery for malignancy.

An initial comparative study of two techniques of laparoscopic colonic anastomosis and mesenteric defect closure

Laparoscopic colon and rectal surgery is still in its nascent stages of development. The ease, efficacy, and safety of intracorporeal mechanical colonic anastomosis are contingent upon expensive stapling devices. Although mobilization and mesenteric division are feasible, a method of inexpensive rapid anastomosis is not. A single inexpensive multifire stapler which could be used both to fashion the anastomosis and to close the mesenteric defect would be ideal. Therefore, this prospective randomized study was undertaken to compare the clinical and functional results of laparoscopic colotomy closure performed using the Endopath EMS hernia stapler (EMS; Ethicon Endosurgery Inc., Cincinnati, OH) to results of using standard two-layer hand suturing (HS). Both the colotomy itself and the mesenteric defect closure sites were included in the randomization and analysis. The abdominal cavity was assessed for evidence of anastomotic leakage, abscess, and adhesion formation. In addition, radiographic luminal diameter, bursting strength, and histology were evaluated. Eight healthy pigs were randomized to either the EMS (N=4) or HS (N=4). There was no evidence of leakage, abscesses, or adhesion formation in either group; however, the mesenteric defect revealed more scarring in the HS than in the EMS animals. There were no significant differences in either luminal diameter (HS: mean=0.92 cm; EMS: mean=0.91 cm) or bursting strength (HS: mean=171 mm Hg; EMS: mean=157 mm Hg) (P>0.05). Histologic analysis also demonstrated no difference in inflammation, necrosis, or fibrosis. This study suggests that this technique can be safely applied to both colotomy closure and mesenteric defect repair. Clinical, histopathologic, and functional results after EMS closure are comparable to standard (HS) closure. Reproduction of this inexpensive means of safe, cost-effective, intracorporeal anastomosis and mesenteric closure should be pursued in human clinical trials.

Simple technique for pelvic drain placement in laparoscopic abdominoperineal resection.

The placement of a pelvic drain after abdominoperineal resection of the rectum is a routine practice. We present a simple technique for laparoscopic placement of such a drain through the abdominal wall following laparoscopic abdominoperineal resection.