Laparoscopic versus open proctectomy for rectal cancer: patients' 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.

Prolonged postlaparoscopy carbon dioxide pneumoperitoneum.

In this article we report what is to our knowledge the longest published duration of postlaparoscopy CO2 pneumoperitoneum, and discuss factors that may contribute to the duration of postoperative pneumoperitoneum.

Intestinal intussusception.

Intussusception is defined as the invagination of one portion of the bowel into an immediately adjacent portion. Etiology, symptoms, diagnosis, and treatment are different in the pediatric and adult populations. In the pediatric population, most cases are idiopathic and result in the common scenario of ileocolic intussusception. Factors involved in causation include anatomic features of the developing gastrointestinal tract and infectious influences. In adults, the intussusceptum is typically the result of a mucosal, intramural, or extrinsic lead point that acts as a focal area of traction pulling the proximal portion of bowel into the peristalsing distal portion. The diagnosis and management in the pediatric population is relatively standardized with nonoperative reduction via air or contrast enemas attempted first. In the adult population, intussusception presents a preoperative diagnostic challenge; although surgical intervention is mandatory, intraoperative management remains controversial.

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

BACKGROUND: Solitary 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 METHODS: A 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. RESULTS: During 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. CONCLUSION: The 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.

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.

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.

Laparoscopic surgery for ulcerative colitis.

Laparoscopic techniques have revolutionized management of colorectal diseases; however, inflammatory diseases of the intestine have proven challenging because of the technical demands of their nature. Intense investigation and subsequent refinements in technique and technology have recently led to considerable advances and a clear role for laparoscopic management of Crohn's disease. and diverticulitis; laparoscopy for ulcerative colitis has not proven as promising. Laparoscopic procedures for ulcerative colitis require a significant learning curve. Although numerous experienced laparoscopic teams have documented their ability to complete them, long operative times and elevated rates of morbidity in some studies appear to counter the advantages. The question remains as to the universal application and appropriateness of these procedures in surgical management of ulcerative colitis.

Physiologic predictors of survival in post-traumatic arrest.

Traumatic cardiac or pulmonary arrest is often associated with a dismal outcome and is considered by many to be an example of medical futility and inappropriate use of resources. This study aimed to identify the predictors of survival in patients experiencing traumatic cardiac arrest. We retrospectively reviewed all trauma patients undergoing cardiopulmonary resuscitation on arrival to the Emergency Department (ED) at an American College of Surgeons-designated Level I trauma center over 4 years. ED survival, hospital survival, and neurologic outcomes on discharge were the primary outcomes. Survival rates were examined in relation to demographics, mechanism of injury, airway management, cardiac electrical rhythm, and pupil size and reactivity. Statistical analyses used chi-square and t tests, P < 0.05 was considered significant. A total of 195 patients arrived in the ED with traumatic cardiac arrest; 34 were pronounced dead on arrival (no signs of life), and no resuscitation efforts were initiated. Of the remaining 161 patients 53 (33%) survived to leave the ED, and only 15 (9%) left the hospital alive. Demographic features were similar in survivors and nonsurvivors. The setting of intubation (prehospital vs ED) did not influence survival (P = 0.36). Penetrating trauma adversely affected survival in the ED (P = 0.01); however, this only approached significance in the final outcome of hospital survival (P = 0.06). The presence of sinus rhythm and nondilated reactive pupils was highly significant in predicting ED and hospital survival (P = 0.001). No patient with agonal rhythm or ventricular fibrillation/tachycardia survived, and 14 of the 15 hospital survivors had reactive pupils on arrival to the ED. We conclude that sinus rhythm and pupil size and reactivity are important physiologic variables that predict potential survival and may be used to guide continuation of resuscitative efforts in patients with traumatic cardiac arrest.