Susan M. Cera

Do elderly patients benefit from laparoscopic colorectal surgery

BackgroundThe steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients.AimTo analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP).MethodsA retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age ≥ 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality.Results641 patients (M/F – 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 – 60%) than in group B (106/234 – 45%) – p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3–17) days versus 8.7 (4–22) days in group B (p <0.0001), and LAP: 5.3 (2–19) days versus 6.4 (2–34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003).ConclusionsElderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes

BackgroundSolitary rectal ulcer syndrome (SRUS) is a rare disorder often misdiagnosed as a malignant ulcer. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless, the endoscopic and clinical presentations may be confusing. The aim of the present study was to assess the clinical findings, surgical treatment, and outcomes in patients who suffer from SRUS.Materials and methodsA retrospective chart review was undertaken, from January 1989 to May 2005 for all patients who were diagnosed with SRUS. Data recorded included: patient’s age, gender, clinical presentation, past surgical history, diagnostic and preoperative workup, operative procedure, complications, and outcomes.ResultsDuring the study period, 23 patients were diagnosed with SRUS. Seven patients received only medical treatment, and in three patients, the ulcer healed after medical treatment. Sixteen patients underwent surgical treatment. In four patients, the symptoms persisted after surgery. Two patients presented with postoperative rectal bleeding requiring surgical intervention. Three patients developed late postoperative sexual dysfunction. One patient continued suffering from rectal pain after a colostomy was constructed. Median follow-up was 14 (range 2–84) months.ConclusionThe results of this study show clearly that every patient with SRUS must be assessed individually. Initial treatment should include conservative measures. In patients with refractory symptoms, surgical treatment should be considered. Results of anterior resection and protocolectomy are satisfactory for solitary rectal ulcer.

Muscle Transposition: Does It Still Have a Role?

Since the early 1900s, skeletal muscle transpositions have been employed for complicated cases of fecal incontinence to augment or replace the anal sphincter. Multiple techniques have evolved that vary with the type and configuration of muscle used in the reconstruction. Transposition of the gluteus maximus muscle was popular in the early stages of development but was replaced by techniques involving transposition of the gracilis muscle. Within the past 16 years, electrical stimulators have been applied to the transposed muscle flaps to create a dynamic reconstruction improving the efficacy of these neosphincters over their static counterparts. However, the stimulated versions are technically demanding with a high rate of morbidity secondary to complications of the multiple components and variations in technique. The stimulator used in this procedure has been removed from the US market, although it is still available in other countries. Currently in the United States, gracilis transposition is still employed in the absence of an electrical stimulator as an adjunct to the artificial bowel sphincter (Acticon Neosphincter, American Medical Systems, Minnetonka, MN), such as in cases of severe muscle loss and congenital atresia. In European countries, the stimulated graciloplasty continues to evolve, leading to expansion of its use in total anorectal reconstruction for anal atresia and after abdominoperineal resection.

Minimally invasive treatment of colon cancer.

The advantages of laparoscopy in the treatment of benign diseases have been well demonstrated. Compared with laparotomy, the laparoscopic approach is associated with a shorter hospitalization period, shorter duration of ileus, decreased postoperative pain, earlier return to work, and improved cosmesis. The role of laparoscopy for the treatment of gastrointestinal malignancy has had a slower evolution and been the subject of considerable debate over the past decade. Since 1991, several concerns have limited the widespread use of laparoscopy for attempted cure of colorectal carcinoma. This review aims to analyze the results of several studies published to date on short and long term outcome of laparoscopy for colorectal carcinoma, based on levels of evidence. From the least to the most convincing data, the hierarchy of study designs progresses through a spectrum ranging from retrospective reviews to prospective series, to case-controlled, cohort, and ultimately randomized controlled trials.

Laparoscopic Versus Open Proctectomy for Rectal Cancer: Patientsʼ Outcome and Oncologic Adequacy

Background The aim of this study was to compare laparoscopic management of rectal cancer to open surgery. Methods The medical records of patients who underwent elective laparoscopic or open proctectomy for rectal cancer between November 2004 and July 2006 were retrospectively reviewed. Results Thirty-two patients in the laparoscopic group (LG) were matched for tumor location, stage, comorbidity, and type of surgical procedure to 50 patients in the open group (OG). There were no statistically significant differences between the groups relative to American Society of Anesthesiologists score or tumor, node, metastasis stage; however, body mass index and age of the LG were significantly lower compared with the OG (P<0.05). In the LG, the procedure was successfully laparoscopically completed in 28 patients (87.5%). The median operative time was 240 minutes in the LG and 185 minutes in the OG (P< 0.05). Overall morbidity was 25% and 38%, respectively (P=0.1), the median hospital stay was 6 days, and median time to first bowel movement was 3 days in the LG compared with 7 and 4 days in the OG, respectively (P=0.7 and 0.01, respectively). The number of identified lymph nodes, distal and radial margins were comparable between both groups. Median follow-up was 10 (1 to 18) months. Conclusions Laparoscopic proctectomy for rectal cancer is feasible in 87.5% of patients and despite a longer operative time compared with laparotomy, is safe with the advantages of faster recovery of bowel function. This procedure does not compromise the oncologic adequacy of resection or significantly differ from open proctectomy relative to short-term outcomes.

Anal Sphincter Repair

Fecal incontinence secondary to sphincter damage is best managed by overlapping sphincteroplasty. The most successful outcomes are found in patients with isolated sphincter defects without evidence of pudendal neuropathy. Multifocal defects and unilateral or bilateral pudendal neuropathy argue for poor outcome. These patients may be better served with postanal or total pelvic floor repair, sacral nerve stimulation, or sphincter augmentation or replacement before embarking on a permanent stoma. All types of surgical intervention for fecal incontinence should simultaneously address other disorders of the pelvic floor and urinary incontinence.

Laparoscopic Right Hemicolectomy

Preoperatively, patients undergo an appropriate medical evaluation. Imaging studies including CT scan, barium studies, and colonoscopy are undertaken for preoperative planning to assess the location of disease, review any associated complications, and identify any synchronous lesions. Preoperative marking of polyps by endoscopic tattooing using India ink is necessary to ensure intraoperative identification of the lesion and to avoid the need for intraoperative colonoscopy. In patients with recurrent Crohn’s disease or history of multiple laparotmoies, imaging studies are particularly important in providing “roadmaps” to define extent of previous resections, length of remaining bowel, and degree of previous mobilization of flexures. Preoperative mechanical and antibiotic bowel preparation consists of 45 cc sodium phosphate solution (Fleets phosphosoda; C.B. Fleet Co., Inc., Lynchburg, VA) PO at 4 pm and at 9 pm, each followed by 3–8 oz glasses of water, and 1 gm neomycin with 500 mg metronidazole at 7∶00 and 11∶00 pm.

Surgical Management of Anal Incontinence Part B. Advanced Surgical Techniques

In the fi rst half of the century, patients who were not candidates for sphincter repair underwent sphincter reconstruction with muscle transpositions involving either the gluteus maximus or gracilis muscles. These techniques only met with moderate success since these static, striated muscle fl aps were prone to fatigue with chronic contraction. The transposed muscle did not have any involuntary tone at rest, and patients had to perform awkward movements to achieve imperfect continence. In the mid-1960s, postanal repair was developed in which a levatorplasty was performed posteriorly to theoretically restore the anorectal angle and lengthen the anal canal. Because of poor longterm success rates, it is of historical signifi cance, though it remains an option for those patients in whom other interventions have failed and who wish to avoid a stoma. In the 1980s, external stimulators were applied to muscle transpositions to create dynamic neosphincters with resting muscle tone. The lowfrequency electrical stimulation provided by these stimulators transforms the skeletal muscle from fast-twitch fatigue-prone (type II) muscle fi bres to slow-twitch fatigue-resistant (type I) muscle fi bres. However, the procedure involves many components and requires technical expertise with a steep learning curve. Short-term results included an array of complications that proved to 12b.

Rectoanal Intussusception, Solitary Rectal Ulcer, and Sigmoidoceles

Intussusception is an epiphenomenon rather than a cause for evacuatory dysfunction and should be conservatively managed. Solitary rectal ulcer syndrome is a consequence of excessive chronic straining, and therapy should be geared toward restoration of normal defecatory habit. Surgical therapies described for SRUS are reserved for patients with severely refractory ulcers, particularly those with persistent hemorrhage. Optimal treatment of sigmoidoceles depends largely on symptomatology and associated conditions. Repair involves sigmoid resection with additional pelvic floor reconstruction for coexisting defects.