International consensus definition of low anterior resection syndrome.

AIM: Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. METHOD: This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. RESULTS: Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSION: This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis.

BACKGROUND: This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques. METHODS: We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection. RESULTS: Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection. CONCLUSION: Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.

Harmonic Scalpel vs. electrocautery hemorrhoidectomy: a prospective evaluation.

INTRODUCTION: Management of posthemorrhoidectomy pain remains a very unsatisfactory clinical dilemma. Compared with electrocautery and laser, the Harmonic Scalpel causes minimal lateral thermal injury during tissue dissection. PURPOSE: The aim of the study was to establish whether decreased lateral thermal injury translated into diminished posthemorrhoidectomy pain. METHODS: A prospective randomized trial comparing Harmonic Scalpel hemorrhoidectomy and electrocautery was undertaken. Fifty consecutive patients were randomized into two groups: Harmonic Scalpels and electrocautery hemorrhoidectomy. The indications included Grade III internal hemorrhoids with external components or Grade IV disease. Patients with additional anorectal pathology (fissure or fistula) were excluded, as were patients with neurologic deficits, chronic pain syndrome, and those already taking narcotic analgesics. Pain was assessed using a visual analog scale preoperatively and on postoperative Days 1, 2, 7, 14, and 28. Twenty-four-hour narcotic usage (Hydrocodone, 10 mg) was recorded on postoperative Days 1, 2, 7, 14, and 28. A three-quadrant modified Ferguson hemorrhoidectomy was performed with each patient in the prone jackknife position. RESULTS: Pain in the Harmonic Scalpel hemorrhoidectomy group was significantly less than in electrocautery patients on each postoperative day studied. Analgesic requirements were also significantly less in the Harmonic Scalpel group on Days 1, 2, 7, and 14. There was no correlation between postoperative pain and grade of hemorrhoid, status of the surgical incision (open vs. closed), or any other study variable. Fifty-five percent of Harmonic Scalpel patients returned to work within one week of surgery, compared with 23 percent of electrocautery patients. CONCLUSION: The study demonstrates significantly reduced postoperative pain after Harmonic Scalpel hemorrhoidectomy compared with electrocautery controls. The diminished postoperative pain in the Harmonic Scalpel group likely results from the avoidance of lateral thermal injury.

Surgical options for familial adenomatous polyposis.

Familial adenomatous polyposis (FAP) is a genetic disorder transmitted in an autosomal dominant pattern. One-half of members of an affected family will carry the gene, and all carriers will succumb to colon cancer or extracolonic manifestations if not detected and treated early. When the diagnosis is made, surgery is indicated. Surgical options include total proctocolectomy with ileostomy, continent ileostomy, total colectomy with ileorectal anastomosis, and total proctocolectomy with ileal pouch anal anastomosis. Many diverse factors, such as extent of rectal disease, the presence and extend of carcinoma, sphincter function, and extracolonic disease, influence which surgical procedure is most appropriate for the individual patient with FAP. This article reviews the surgical options for treating FAP, with emphasis on specific indications, contraindications, and anticipated outcomes.

Laparoscopically assisted bowel surgery. Analysis of 114 cases.

In order to help determine the risks and benefits, we retrospectively analyzed the results of our first 114 laparoscopically assisted bowel procedures. Procedures performed consisted of partial colectomy (85), total or subtotal abdominal colectomy (8), total proctocolectomy with J-pouch ileal reservoir (11), and diverting procedures (10). Forty-nine procedures were for malignancy. The rate of conversion to laparotomy was 13.2%. Oral feedings were resumed in 2.4 days (range 1-5), and bowel function returned in 3.8 days (range 2-8). The average length of stay was 4.2 days for partial colectomy and 6 days for total, subtotal, and proctocolectomy. The mean return to normal activity for all groups was 16.7 days (10.8 days for partial colectomy). There were no deaths. Major morbidity (6%) consisted of abscess (3), anastomotic leak (2), and hemorrhage (1). Mean operative costs analyzed for the initial 37 patients were higher for laparoscopic colectomies when compared to traditional colectomies; however, the mean total hospital costs were less for the laparoscopic procedures. These data suggest that the laparoscopic approach to colorectal resection is an acceptable alternative to laparotomy for a variety of disease processes, allowing patients an early return to normal activity.

Laparoscopic surgery for colorectal neoplasms.

Laparoscopy is being used to assist in an increasing number and variety of bowel procedures. However, when being used for neoplastic disease concerns of margins and adequacy of mesenteric dissection must be addressed. We've performed 110 laparoscopic-assisted bowel procedures, with 45 of these performed for neoplastic disease. Ninety-two bowel resections were performed including 24 subtotal, total, or proctocolectomies. In this chapter we review the results of our series, as well as other reported series, and discuss some of the controversies involved with laparoscopy for neoplastic disease.

A complex ileovaginal fistula with associated obstructive uropathy in a patient with Crohn's disease: technical considerations and review of the literature.

A high index of suspicion of an ileogenital fistula should be aroused by a patient with Crohn's disease, weight loss, malnutrition, and a persistent vaginal discharge. Preoperative gastrointestinal and genitourinary evaluation should be used in an attempt to localize the fistulous origin as well as concomitant fistulae. The principles of surgical therapy include preoperative ureteral catheters, resection of the diseased bowel and fistulous segment of bowel, and interposition of healthy tissue (ie, omentum) between the bowel anastomosis and the vaginal cuff.

Management of hemophilia in colon and rectal surgery. Report of a patient with factor VIII inhibitors and review of the literature.

With the introduction of Factor VIII concentrates, surgery on patients with hemophilia has become possible. The mortality in recent large series is zero. The morbidity has been variable, with postoperative hemorrhage the most common complication. There is a dramatic change in therapeutic strategy with the development of Factor VIII inhibitors. In reviewing the literature, there are no reports discussing this patient population with respect to the subspecialty of colon and rectal surgery. The authors present a report of a patient with hemophilia who, after hemorroidectomy, developed Factor VIII inhibitors and continued hemorrhage. This article also reviews the literature and centralizes the management of colon and rectal surgery patients with hemophilia.

Diffuse cavernous hemangioma of the rectosigmoid--CT scan, a new diagnostic modality, and surgical management using sphincter-saving procedures. Report of three cases.

Diffuse cavernous hemangioma of the rectosigmoid is a rare lesion. Preoperative recognition has been recorded but, because of lack of awareness and inconsistent diagnoses, inappropriate therapy still persists. Surgical therapy is the hallmark of treatment. Abdominoperineal resection has been advocated. Three cases of diffuse cavernous hemangiomas of the rectosigmoid, recognized preoperatively and treated successfully with sphincter-saving procedures, are reported. Use of the CT scan as a consistent diagnostic tool will be presented for the first time.

The Chilaiditi syndrome and associated volvulus of the transverse colon. An indication for surgical therapy.

Hepatodiaphragmatic interposition of the colon is a rare anomaly described by Chilaiditi in 1910. Usually this syndrome presents as an asymptomatic roentgen finding, although occasionally it is associated with a broad range of gastrointestinal symptoms. The hallmark of therapy is conservative, and rarely has surgical intervention been indicated. This is the only case report of the Chilaiditi syndrome associated with colonic volvulus. It also illustrates the rare progression of colonic interposition from mild abdominal discomfort to intermittent bowel obstruction requiring surgical intervention.

The effects of ileal resection with cholecystectomy on bile salt metabolism in the prairie dog.

The adverse effects of ileal resection on bile salt metabolism may be aggravated by cholecystectomy. Female prairie dogs had either sham laparotomy, cholecystectomy, distal 50% small bowel resection, or cholecystectomy and distal 50% small bowel resection. After 4 weeks the common bile duct was cannulated and bile collected for up to 12 hr. Bile salt pool size and synthetic rate were measured from the washout curve. Bile salt, phospholipid, and cholesterol concentrations were determined. Bile salt pool size was reduced after cholecystectomy and after ileal resection. Cholecystectomy plus ileal resection further lowered the pool size, increased the synthetic rate, and increased the proportion of secondary bile salts. Cholecystectomy increased the synthesis and the concentration of bile salts in hepatic bile and altered the proportions of biliary lipids. Ileal resection decreased the concentration of hepatic bile salts with the formation of noncholesterol stones. The drastic reduction in pool size with the combined operation might be expected to lead to fat malabsorption. The higher concentration of bile salts after the combined operation compared with ileal resection alone reflects a possible beneficial effect of cholecystectomy.

A new type of continent ileostomy. Results of an animal study.

Kock's continent ileostomy is a well-established technique, however, it is technically difficult to construct and has a high incidence of complications. This study evaluates a new type of mucosal valve constructed in continuity with an intestinal reservoir. The valve is created along the antimesenteric border of the efferent limb 0.5 cm distal to the reservoir. The seromuscular layer is "stripped" from the mucosal layer for 50 per cent of the bowel circumference and then excised. The remaining seromuscular borders are then sutured to the apex of the pouch and along the antimesenteric border of the afferent limb. In this way the valve is created and, upon distention of the afferent limb and apex of the pouch, the valve closes. In seven dogs such a continent ileostomy was constructed and all were clinically continent. The reservoirs were intubated through the ileostomy two to three times a day. The mean volume aspirated was 143 ml/day. After eight weeks, radiographic and volume-pressure studies were performed. Prior to sacrifice, increasing volumes of barium were instilled into each pouch via the afferent limb and radiographs were taken: these studies confirmed the continence in all seven ileostomies. Following this the reservoirs were intubated and the instilled barium was aspirated. Then Ringer's solution was instilled into each pouch with continuous intrapouch pressure measurements. The pressure remained at 0 cmH2O until a mean volume of 243 ml was exceeded. The mean volume at which incontinence occurred was 415 ml.

Soft tissue infections in parenteral drug abusers.

Thirty-four parenteral drug abusers admitted with soft tissue infections underwent bacteriologic and immunologic evaluation. Staphylococcus aureus and beta hemolytic streptococci were the most common organisms recovered. Enteric gram negative aerobes and oral flora were common and enteric anaerobes rare. Absolute lymphopenia and elevations in the IgA, IgG and IgM fractions of the immunoglobulins were common as were false positive VDRL examinations. Cutaneous anergy was found in 83% of the group and 70% of a simultaneously noninfected addict group. Staphylococcal carriage was frequent. Because of variation in the flora between this and other reported groups, ongoing bacteriologic surveillance could be a useful guide to initial antibiotic therapy. Differences in the pattern of immune reaction in this group when compared to different addict groups suggest a difference in antigenic stimulation, possibly as a result of differences in bacteriologic exposure.

Infections in parenteral drug abusers. Further immunologic studies.

In our previous study of soft tissue infections in parenteral drug abusers, two thirds of the infections were polymicrobial. Oral and enteric organisms were frequently recovered. These patients and a group of uninfected addicts showed frequent cutaneous anergy, lymphopenia, and hypergammaglobulinemia. An additional group of uninfected addicts was studied. The mean levels of IgA, IgG, and IgM were higher in the uninfected addicts. In the addict and control groups, elevations in IgA (17 percent of total), IgG (65 percent), and IgM (19 percent) levels were found. Zinc levels were within normal limits. T-cell populations below 70 percent were seen in five of the seven addicts and two of the four control subjects. Reversed helper to suppressor cell ratios were found in three of the seven addicts and control subjects. No consistent pattern of immunologic abnormalities emerged. The interrelationship of the abnormalities in the addict and their relationship to AIDS is unclear.

Gastrointestinal bleeding in the elderly. Morbidity, mortality and cause.

One hundred thirty-six consecutive patients with upper gastrointestinal bleeding were divided by age into three groups, young, middle aged and elderly, and evaluated for the causes and complications of the bleeding episode. Hemorrhagic gastritis was the most frequent source of bleeding in the young, while gastric ulcer was more common in the middle aged and elderly groups. The high mortality in the young (20 percent) was often attributable to associated liver functional abnormalities secondary to alcoholism. The elderly fared better than the young when the source of bleeding was hemorrhagic gastritis, although the results were not statistically significant. On the other hand, the elderly had a significantly higher mortality than the young when the source was gastric ulcer. All three groups did poorly when the source of bleeding was esophageal varices. The mortality rate was essentially the same in the young and elderly patients requiring surgery, suggesting that age alone should not be a deterrent for surgical management of acute gastrointestinal bleeding.