Zuri Murrell

Management of Colonic Volvulus

Colonic volvulus is a common cause of large bowel obstruction worldwide. It can affect all parts of the colon, but most commonly occurs in the sigmoid and cecal areas. This disease has been described for centuries, and was studied by Hippocrates himself. Currently, colonic volvulus is the third most common cause of large bowel obstruction worldwide, and is responsible for ∼15% of large bowel obstructions in the United States. This article will discuss the history of colonic volvulus, and the predisposing factors that lead to this disease. Moreover, the epidemiology and diagnosis of each type of colonic volvulus, along with the various treatment options will be reviewed.

Management of Early Rectal T1 and T2 Cancers

The treatment of rectal cancer has undergone a tremendous surgical evolution over the past century. Initially, in the 19th century, the only possible safe treatment was a diverting colostomy, which then evolved first to local treatment, primarily via the Lisfranc and Kraske procedures (posterior approach), and later, in the 20th century, to the abdominal-perineal resection popularized by Miles. Subsequently, anterior resection and low anterior resection gained a solid foothold as the most efficacious ways to treat most cancers of the rectum. In the past 3 decades, transanal excision has reemerged as a popular treatment option for T1 and selected T2 rectal adenocarcinomas, allowing less morbidity for early cancers. The selection criteria for this treatment have often included mobile tumor, size <4 cm, favorable histology without lymphovascular invasion, and anatomic accessibility with the ability to achieve 1-cm circumferential margins. Although the use of transanal excision for T1 rectal cancer increased from 26% to ∼44% between 1989 and 2003, multiple recent retrospective studies have suggested that locoregional recurrence after this procedure is as high as 18% for T1 cancers and 47% for T2 cancers. Of interest, limited available prospective data reveal much better results (4-5% locoregional recurrence rate for T1 and 14-16% for T2). Much of the apparent discrepancy is due to patient selection, which is far more rigid in prospective trials. Conflicting data also exist as to how this outcome affects overall survival, although surgical salvage averages ∼50% with close follow-up. The following topics will be discussed in this article: the surgical evolution of rectal cancer, best patient selection criteria for transanal excision versus more radical operation, utility and effect of adjuvant therapy in early-stage rectal cancer, current trends in the treatment of early-stage rectal cancer, and current early-stage rectal cancer trials.

A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn's disease.

Objective:To evaluate 2- and 12-month outcomes after ligation of the intersphincteric fistula tract (LIFT) in Crohns disease (CD). Background:Surgical approaches to perianal fistulas in CD are frequently ineffective and hampered by concerns over adequate wound healing and sphincter injury. The efficacy of LIFT in CD patients is unknown. Methods:Consecutive cases of CD patients with transsphincteric fistulas were prospectively analyzed. Fistula healing and 2 validated quality-of-life indices were assessed. Results:Fifteen CD patients (9 women; mean age = 34.8 years) were identified. Location of the fistula was lateral (n = 10; 67%) or midline (n = 5; 33%). LIFT site healing was seen in 9 patients (60%) at 2-month follow-up. No patient developed fecal incontinence. LIFT site healing was seen in 8 of the 12 patients (67%) with complete 12-month follow-up. Significant factors for long-term LIFT site healing were lateral versus midline location (P = 0.02) and longer mean fistula length (P = 0.02). Patients who had successful operations significantly improved both their mean Wexner Perianal Crohns Disease Activity Index and McMaster Perianal Crohns Disease Activity Index quality-of-life scores at 2-month follow-up (14.0–3.8, P = 0.001, and 10.4–1.8, P = 0.0001, respectively). Conclusions:CD-associated anal fistulas may be treated with LIFT. This surgical procedure is a safe, outpatient procedure that minimizes both perianal wound creation and sphincter injury.

A Prospective Randomized Controlled Trial of Sugared Chewing Gum on Gastrointestinal Recovery After Major Colorectal Surgery in Patients Managed With Early Enteral Feeding

BACKGROUND: A number of small prospective studies with conflicting results have evaluated the effect of sugar-free chewing gum on postoperative GI recovery in patients initially maintained nil per os after major colorectal surgery. OBJECTIVE: We sought to evaluate the effect of sugared chewing gum in combination with early enteral feeding on recovery of GI function after major colorectal surgery to ascertain any additive effects of this combination. DESIGN: This was a randomized prospective study. SETTING: This study was conducted at a single-institution tertiary referral center. PATIENTS: Patients undergoing major colorectal surgery were included. INTERVENTIONS: Patients were randomly assigned to sugared chewing gum (Gum) (instructed to chew 3 times daily; 45 minutes each time for 7 days postoperatively) or No Gum after major colorectal surgery. MAIN OUTCOME MEASURES: The primary outcome measured was time to tolerating low residue diet without emesis for 24 hours. The secondary outcomes measured were time to flatus, time to bowel movement, postoperative hospital stay, postoperative pain, nausea, and appetite. RESULTS: One hundred fourteen patients (60 No Gum; 54 Gum) were included in our analysis after randomization. There was no significant difference in time to tolerating a low-residue diet, time to flatus, time to bowel movement, length of postoperative hospital stay, postoperative complications, postoperative pain, nausea, or appetite between patients assigned to Gum or No Gum. There was an increased incidence of bloating, indigestion, and eructation in the Gum group (13%) in comparison with the No Gum group (2%) (p = 0.03). LIMITATIONS: Study subjects and investigators were not blinded. Multiple types of operations may cause intergroup variability. CONCLUSIONS: There does not appear to be any benefit to sugared chewing gum in comparison with no gum in patients undergoing major colorectal surgery managed with early feeding in the postoperative period. There may be increased incidence of bloating, indigestion, and eructation, possibly related to swallowed air during gum chewing.

A prospective evaluation of the long-term outcome of ileal pouch-anal anastomosis in patients with inflammatory bowel disease-unclassified and indeterminate colitis.

PURPOSE: The long-term outcome of ileal pouch-anal anastomosis in patients with indeterminate colitis is controversial. The aim of this study was to prospectively evaluate the long-term outcome of ileal pouch-anal anastomosis in a closely monitored cohort of patients with ulcerative colitis or indeterminate colitis. METHODS: Prospectively generated clinical profiles on consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis with close postoperative follow-up by one surgeon were reviewed. All patients were classified before surgery as either ulcerative colitis or inflammatory bowel disease-unclassified, and after surgery as either ulcerative colitis or indeterminate colitis. Long-term outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohns disease (small inflammation above the pouch inlet or pouch fistula). RESULTS: The study cohort of 334 patients were classified before surgery as ulcerative colitis in 237 (71 percent) and inflammatory bowel disease-unclassified in 97 (29 percent). After surgery, patients were classified as ulcerative colitis in 236 (71 percent) and indeterminate colitis in 98 (29 percent). After a median follow-up after stoma closure of 26 months, 53 patients (16 percent) developed acute pouchitis, 37 patients (11 percent) developed chronic pouchitis, and 40 patients (12 percent) developed de novo Crohns disease. There was no significant difference in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohns disease between the ulcerative colitis, inflammatory bowel disease-unclassified, and indeterminate colitis patient groups. CONCLUSION: The incidence of acute pouchitis, chronic pouchitis, and de novo Crohns disease after ileal pouch-anal anastomosis do not differ significantly between patients with ulcerative colitis, inflammatory bowel disease-unclassified, or indeterminate colitis. Patients with inflammatory bowel disease-unclassified and indeterminate colitis can undergo ileal pouch-anal anastomosis and expect a long-term outcome equivalent to patients with ulcerative colitis.

Surgical Outcome of Ileal Pouch—Anal Anastomosis When Used Intentionally for Well-Defined Crohn's Disease

Background:Crohns disease (CD) is considered a contraindication to ileal pouch—anal anastomosis (IPAA). In this study, we compare outcomes of CD and ulcerative colitis (UC) patients undergoing IPAA. Methods:Patients were considered to have CD before surgery based on a history of small bowel disease, perianal disease, noncrypt-associated granuloma, or pretreatment skip colonic lesions. Patients were prospectively assessed for pouchitis or CD. Postoperative CD (pouch inflammation into the afferent limb or pouch fistula) or pouch failure (need for permanent diversion) were assessed. Preoperative serum was assayed for IBD-associated antibodies using enzyme-linked immunosorbent assay (ELISA). Results:Seventeen patients with preoperative CD were identified. Seven (41%) patients developed postoperative recurrent CD in the afferent limb (n = 3) or pouch fistulizing disease (n = 4). One patient (6%) required pouch excision. The incidence of postoperative CD was higher (P = 0.002) in preoperative CD patients (41%) than UC patients (11%). There was no significant difference in pouchitis or pouch failure. There was also no significant difference in any preoperative clinical feature between patients with or without postoperative CD. Afferent limb inflammation developed in three (50%) of the six patients with pANCA+/OmpC− expression compared to none of the 11 patients without this serologic profile (P = 0.03). Conclusions:Although the intentional use of IPAA in CD has a higher incidence of postoperative disease vs. UC patients, there was no significant difference in pouch failure. Demographics, clinical features, and serologic factors do not predict outcome of CD patients undergoing IPAA. IBD serology may identify the phenotype manifestation of postoperative recurrent CD.

Reoperation for anastomotic failure.

Anastomotic leak is a dreaded complication of colorectal surgery, with many potential causes. This complication carries with it a reported mortality ranging from 6 to 39%. Early diagnosis is key for the prevention of mortality. Here, we discuss the causes of an anastomotic leak and its signs and symptoms. Moreover, we explore the various modalities of diagnosis and treatment options. Most important, we discuss when a patient needs to be taken to the operating room and what procedure should be performed given various intraoperative findings.

Preoperative wireless capsule endoscopy does not predict outcome after ileal pouch-anal anastomosis.

PURPOSE: The extent of preoperative small-bowel mucosal inflammation may be an important predictor of pouchitis after ileal pouch-anal anastomosis. This study examined the value of preoperative wireless capsule endoscopy in predicting outcome of ileal pouch-anal anastomosis in patients with ulcerative colitis or indeterminate colitis. METHODS: Patients undergoing complete wireless capsule endoscopy before ileal pouch-anal anastomosis were identified. Findings on wireless capsule endoscopy were classified as positive (erosions, ulcers or erythema) or negative. Outcome was assessed prospectively and included no pouchitis, acute pouchitis, chronic pouchitis, or de novo Crohn disease. Patients with acute pouchitis, chronic pouchitis, or de novo Crohn disease were considered to have pouch inflammation. RESULTS: The 68 study patients (48 ulcerative colitis; 20 indeterminate colitis) had a median age of 38 years and included 34 males. Median follow-up time after ileostomy closure was 12 months (range, 3–63 months). Wireless capsule endoscopy was positive in 15 patients (22%) and negative in 53 patients (78%). Pouch inflammation was observed in 23 patients (34%), and included 8 patients with acute pouchitis, 3 patients with chronic pouchitis, and 12 patients with de novo Crohn disease. The incidence of acute pouchitis, chronic pouchitis, de novo Crohn disease, and pouch inflammation in the wireless capsule endoscopy-positive patient group was 7%, 7%, 20%, and 33% compared with 13%, 4%, 17%, and 34% in the wireless capsule endoscopy-negative patient group (all P = NS). CONCLUSION: There was no statistical association between the results of preoperative wireless capsule endoscopy and outcome after ileal pouch-anal anastomosis in patients with ulcerative colitis or indeterminate colitis. There seems to be little value of wireless capsule endoscopy in the preoperative evaluation of these patients.

Scarless single-incision laparoscopic loop ileostomy: a novel technique.

BACKGROUND: Laparoscopic surgery has become a favorable alternative to conventional open surgery for the creation of intestinal stomas, and it offers many benefits including reduced postoperative pain, ileus, and hospital stay. Single-incision laparoscopic surgery has been described for many abdominal operations. It may offer better cosmetic outcomes and reduce incisional pain, adhesions, and recovery time. OBJECTIVE: In this study, we aimed to describe a novel technique of scarless single-incision laparoscopic loop ileostomy for fecal diversion and to report our experience with 8 patients who underwent this procedure within a 1-year period. DESIGN: This study was designed as a retrospective case series. SETTINGS: This investigation was conducted at a single-institution, tertiary referral center. PATIENTS: Eight consecutive patients undergoing scarless single-incision laparoscopic loop ileostomy between August 2009 and August 2010 were included. INTERVENTION: Scarless single-incision laparoscopic loop ileostomies were performed. MAIN OUTCOME MEASURES: Among the outcomes measured were operation time, intraoperative blood loss, recovery of intestinal function, length of hospital stay, and surgical complications. RESULTS: Seven patients underwent surgery for active Crohns disease refractory to medical therapy. One patient underwent surgery for radiation-induced rectovesical fistula. Median surgery time was 76 minutes, and median intraoperative blood loss was 10 mL. Median length of postoperative hospitalization was 7 days. Of the 8 patients included in our series, 2 patients (25%) required reoperation for stoma ischemia because of vascular congestion that we attribute to a tight fascial opening or extensive bowel manipulation. Other surgical complications included nonoperative readmission for ileus and partial small-bowel obstruction (n = 2), anal dilation to evacuate an obstructed distal colon (n = 1), and peristomal cellulitis (n = 1). LIMITATIONS: This study was limited by its small sample size and its retrospective nature. CONCLUSION: Scarless single-incision laparoscopic loop ileostomy is a feasible alternative to standard laparoscopy for fecal diversion. Surgeons attempting this technique should do so with caution, given the high stoma ischemia rate in our small case series.

Safety and feasibility of using low-dose perioperative intravenous steroids in inflammatory bowel disease patients undergoing major colorectal surgery: A pilot study.

BACKGROUND High-dose perioperative corticosteroids are the standard of care for steroid-treated patients undergoing surgery. There is little evidence, however, to support this practice. We investigated the safety of perioperative low-dose steroids in patients with inflammatory bowel disease (IBD) undergoing major colorectal surgery. METHODS Steroid-treated IBD patients undergoing major colorectal surgery were treated with the intravenous equivalent of their preoperative steroid dose in the perioperative period. Patients who were not taking steroids at the time of operation but who were treated with steroids within 1 year of surgery received no perioperative corticosteroids. Perioperative vital signs were analyzed. Hemodynamic instability was defined as heart rate >120 beats per minute, heart rate <60 beats per minute, or systolic blood pressure <90 mm Hg. RESULTS Thirty-two procedures were performed on 10 patients on steroids at the time of operation and 22 patients had who stopped steroids within 1 year of surgery. Five patients (16%) developed tachycardia and 8 patients (25%) had bradycardia. Hypotension occurred in 5 (16%) patients. All cases of hemodynamic instability resolved with no intervention, fluid boluses, or blood transfusion. No patients required vasopressors or high-dose corticosteroids for adrenal insufficiency. CONCLUSION In steroid-treated IBD patients undergoing major colorectal surgery, the use of low-dose perioperative corticosteroids seems safe. A prospective study assessing perioperative corticosteroid dosing is in progress.