Determination of the peritoneal reflection using intraoperative proctoscopy.

PURPOSE: Rectal carcinomas are amenable to transanal excision in 3 to 5 percent of cases. Location below the peritoneal reflection is one requirement for transanal excision and transanal endoscopic microsurgery. The location of the peritoneal reflection has not been extensively studied in living patients. METHODS: This study investigated the location of the peritoneal reflection in 50 patients undergoing laparotomy. The distance from the anal verge to the peritoneal reflection was measured in each patient via simultaneous intraoperative proctoscopy and intra-abdominal visualization of the peritoneal reflection. The mean distance to the peritoneal reflection, range of measurements, and complications of proctoscopy were recorded. RESULTS: Intraoperative proctoscopy was performed on 50 patients after informed consent. The mean lengths of the peritoneal reflection were 9 cm anteriorly, 12.2 cm laterally, and 14.8 cm posteriorly for females, and 9.7 cm anteriorly, 12.8 cm laterally, and 15.5 cm posteriorly for males. The lengths of the anterior, lateral, and posterior peritoneal measurements were statistically different from one another, regardless of gender (P < 0.01). There were no complications of proctoscopy. CONCLUSIONS: Our data indicated that the peritoneal reflection is located higher on the rectum than reported in autopsy studies, and that there is no difference between males and females. Knowledge of the location and position of a rectal carcinoma in relationship to the peritoneal reflection will help the surgeon optimize the use of transanal techniques of resection.

Long-term follow-up of the modified Delorme procedure for rectal prolapse.

HYPOTHESIS: The modified Delorme operation is a safe, effective, and durable treatment for complete rectal prolapse. DESIGN: Retrospective analysis of outcomes in adult patients undergoing the modified Delorme operation. SETTING: Community-based tertiary referral center with a 5-year general surgery residency program. PATIENTS: A total of 52 consecutive patients undergoing surgery for the treatment of complete rectal prolapse during the 26-year period ending December 2001. INTERVENTIONS: Modified Delorme operation. Main Outcomes Measured Method of anesthesia, morbidity, mortality, recurrence rates, length of follow-up, and incontinence. RESULTS: In the 52 patients, the mean length of prolapse was 8.2 cm. The mean operating time was 75 minutes. Forty-five patients were administered general anesthesia, 4 were administered spinal anesthesia, and 3 were administered local anesthesia. The mean postoperative stay was 4.9 days for 1975 through 2001 and 2.8 days for 1990 through 2001. No patients died as a result of the procedure. Patients were followed up for 61.4 months. Major medical comorbidities occurred in 40 patients. Preoperative incontinence was present in 12 patients, 10 of whom improved after the procedure, and postoperative incontinence in 8. The recurrent postoperative prolapse rate at 5 years was 6% (3/52) and the recurrent postoperative prolapse rate to the end of the study was 10% (5/52). Two patients (4%) had complications that required operative intervention in the postoperative period. CONCLUSIONS: The modified Delorme operation is a safe and effective surgical treatment for complete rectal prolapse. The risk of recurrent prolapse is low, and the procedure may be safely performed in patients with significant medical comorbidities.

Obesity: is there an increase in perioperative complications in those undergoing elective colon and rectal resection for carcinoma?

The hypothesis of this study was that obese and overweight patients undergoing elective resection for colon and rectal cancer have longer operative times, increased intraoperative blood loss, and more postoperative complications compared with normal-weight individuals. Our study cohorts included all patients undergoing elective first-time colon resection for proven colorectal carcinoma. Patients undergoing resection for recurrent disease or for emergent indications such as obstruction, perforation, or hemorrhage and those who underwent an additional surgical procedure at the time of colon resection were excluded from analysis. We conducted a retrospective chart review of all patients undergoing resection for colorectal carcinoma during a 30-month period. One hundred fifty-three consecutive patients were identified. Body Mass Index was calculated for each patient. Each patient was labeled as normal, overweight, or obese on the basis of World Health Organization criteria. Estimated intraoperative blood loss, duration of surgery, and postoperative complications were recorded for each patient. Comparisons of continuous variables were made using one- or two-way analysis of variance testing. Comparisons of discrete variables were made with chi-square testing. Level of confidence was defined as P < 0.05. Forty-eight normal, 54 overweight, and 51 obese patients were identified. The type of colon resection, age range, and premorbid conditions were well matched between groups. There was no statistical difference in intraoperative blood loss between groups. The operative times were statistically longer in obese and overweight groups compared with the normal group. No statistical differences existed in postoperative complications between groups. We conclude that obese and overweight patients undergoing resection for colorectal carcinoma when compared with normal-weight patients have similar intraoperative blood loss and postoperative complications but longer operative times.