Local excision for T1 rectal tumours: are we getting better?

AIM: The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS). METHODS: Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed. RESULTS: Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P < 0.001). In unadjusted analysis, there was no significant difference in 5-year OS between the LE and RR groups (P = 0.639) and between the two LE time periods (P = 0.509), which was consistent with the adjusted analysis (LE vs RR, hazard ratio 1.05, 95% CI 0.92-1.20, P = 0.468; 2008-2010 LE vs 2011-2016 LE, hazard ratio 1.09, 95% CI 0.92-1.29, P = 0.321). Laparoscopic LE was associated with improved OS in the unadjusted analysis only (P = 0.006), compared to the open LE group (hazard ratio 0.94, 95% CI 0.78-1.12, P = 0.495). CONCLUSIONS: This study supports the use of a LE approach for T1 rectal tumours as a strategy to reduce surgical morbidity without compromising survival.

Survivorship care for early-stage colorectal cancer: a national survey of general surgeons and colorectal surgeons.

AIM: Few data are available on the optimal long-term care of early-stage colorectal cancer survivors, termed survivorship care. We aimed to investigate current practice in the management of patients following treatment for early-stage colorectal cancer. METHOD: We performed an internet survey of members of the American Society for Colon and Rectal Surgeons about several aspects of long-term care, including allocation of clinician responsibility, challenges with transitions to primary care physicians (PCPs), long-term care plan provision and recommended surgical follow-up duration. RESULTS: Overall, 251 surgeons responded. Surgeons reported taking primary responsibility for managing adverse surgical effects (93.2%) and surveillance testing (imaging and laboratories 68.6%, endoscopy 82.4%). Barriers to PCP handoffs included patient preference for surgical follow-up (endorsed by 76.6%) and inadequate communication with PCPs (endorsed by 36.9%). Approximately one-third of surgeons routinely provide survivorship care plans to PCPs; surgeons who received formal survivorship training were more likely to do so compared to those without such training (OR 3.29, 95% CI 1.57, 6.92). Although only 20.4% of surgeons follow their patients beyond 5 years, individuals in practice longer were more likely to continue long-term follow-up than those with ≤ 10 years of experience. CONCLUSIONS: This is the largest survey of surgeons regarding long-term management for early-stage colorectal cancer and highlights the potential for improved coordination with PCPs and increased implementation of survivorship care plans.

Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database.

AIM: The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS: A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION: Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.

Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status.

PURPOSE: Research examining effects of ostomy use on sexual outcomes is limited. Patients with colorectal cancer were compared on sexual outcomes and body image based on ostomy status (never, past, and current ostomy). Differences in depression were also examined. METHODS: Patients were prospectively recruited during clinic visits and by tumor registry mailings. Patients with colorectal cancer (N = 141; 18 past ostomy; 25 current ostomy; and 98 no ostomy history) completed surveys assessing sexual outcomes (medical impact on sexual function, Female Sexual Function Index, International Index of Erectile Function), body image distress (Body Image Scale), and depressive symptoms (Center for Epidemiologic Studies Depression Scale-Short Form). Clinical information was obtained through patient validated self-report measures and medical records. RESULTS: Most participants reported sexual function in the dysfunctional range using established cut-off scores. In analyses adjusting for demographic and medical covariates and depression, significant group differences were found for ostomy status on impact on sexual function (p < .001), female sexual function (p = .01), and body image (p < .001). The current and past ostomy groups reported worse impact on sexual function than those who never had an ostomy (p < .001); similar differences were found for female sexual function. The current ostomy group reported worse body image distress than those who never had an ostomy (p < .001). No differences were found across the groups for depressive symptoms (p = .33) or male sexual or erectile function (p values ≥ .59). CONCLUSIONS: Colorectal cancer treatment puts patients at risk for sexual difficulties and some difficulties may be more pronounced for patients with ostomies as part of their treatment. Clinical information and support should be offered.

Prophylactic ureteric catheters in laparoscopic colorectal surgery.

BACKGROUND: The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure. METHODS: Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed. RESULTS: Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group. CONCLUSION: Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Early experience with the bioabsorbable anal fistula plug.

PURPOSE: Management of anal fistula represents a balance between curing the condition and maintaining anal continence. Recent reports of the results of the porcine anal fistula plug have demonstrated excellent fistula healing rates without reporting significant complications. METHODS: The outcome of patients who underwent treatment for anal fistula with the Surgisis anal plug was retrospectively reviewed. RESULTS: Twenty patients were treated; three underwent concomitant anal advancement flap at the time of plug placement. Seventeen patients had a trans-sphincteric fistula, and three had an anoperineal fistula. Ten patients had previously undergone failed surgical therapy to cure their fistula, including anal advancement flap in four, muscle interposition flap in two, fistulotomy in two, and cutting seton placement in two. Mean follow-up was 7.4 months. Only 4 of 17 (24%) patients treated with the plug alone had closure of their fistula. Acute postoperative sepsis was seen in 5 of 17 (29%) patients treated with the plug alone. Four developed perianal abscesses that required incision and drainage, and one intersphincteric abscess was treated with antibiotics. Two of the patients who underwent concomitant anal advancement flaps and plug placement healed successfully. CONCLUSIONS: Contrary to other published series, the use of the Surgisis anal plug was associated with a low rate of fistula healing and a high incidence of perianal sepsis. The addition of a transanal advancement flap to the procedure may improve success rates.

An interesting case of mistaken identity.

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder which can present in patients being evaluated for defecatory disorders or which can present as a primary process often involving hematochezia, rectal pain and tenesmus. Unfortunately the diagnosis of this disorder is often delayed due to misdiagnosis and/or physician unfamiliarity with the condition. We present a 24-year-old female who presented with 6 months of bloody diarrhea and weight loss. She had been receiving treatment for a presumed diagnosis of inflammatory bowel disease (IBD) due to an endoscopic picture of rectal thickening, edema and ulceration and had been on prednisone for 2 months prior to presentation without relief of her symptoms. After further testing including repeat endoscopy with biopsies, defecography and anorectal manometry, the diagnosis of SRUS was made and treatment was changed. Medical management was unsuccessful and she ultimately required surgical intervention. This case highlights the difficulty in diagnosing SRUS due to its resemblance to other gastrointestinal diseases and should serve as a reminder that if a patient is not responding to IBD therapy, another etiology should be considered.

Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness.

BACKGROUND: Numerous studies have demonstrated the feasibility of laparoscopy in the management of acute adhesive small-bowel obstruction (AASBO). However, comparative data with laparotomy are lacking. The aim of this study was to compare laparoscopy and laparotomy for the treatment of AASBO in terms of patient outcome and cost-effectiveness. METHODS: A retrospective chart review of all patients who underwent surgery for AASBO from 1999 to 2005 was conducted. Data recorded included operative and postoperative course, among others. Operative and total hospital charges were estimated from the Patient Accounting System. RESULTS: Thirty-one patients who underwent laparoscopy were matched to a similar group of patients who underwent laparotomy. In the laparoscopy group, four patients (13%) had a laparoscopy-assisted procedure and ten patients (32%) were converted. The laparoscopy group was subdivided into laparoscopy, laparoscopy-assisted, converted, and assisted-converted subgroups. In the majority of the patients, AASBO was secondary to a single band. Overall morbidity was significantly higher in the laparotomy group (p = 0.007). Morbidity rates were statistically significant between the laparoscopy and assisted-converted subgroups (p = 0.0001) but not between the laparotomy group and assisted-converted subgroup (p = 0.19). Median hospital stay and median time to first bowel movement were significantly shorter in the laparoscopy group. Charge data were available for only the last three years of the study. Operative charges and total hospital charges were similar between the laparoscopy and the laparotomy groups (p = 0.14 and p = 0.10, respectively). There was a significant difference in total hospital charges between the laparoscopy subgroup and laparotomy group (p = 0.03). CONCLUSIONS: Laparoscopy for AASBO is associated with reduced hospital stay, early recovery, and decreased morbidity. Laparoscopy-assisted and converted surgeries do not differ significantly from laparotomy in regard to patient outcome. Operative and total hospital charges are similar for both laparoscopy and laparotomy.

Laparoscopic rectopexy.

Abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0-12% and fecal continence has been documented to improve in 3-75% of patients. As most patients are elderly and not always fit enough to undergo abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures have a recurrence of up to 38%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a laparoscopic rectopexy on 72-year-old lady with a 10-year history of fecal incontinence and mucosal rectal prolapse. Electronic supplementary material is available for this article at http://dx.doi.org/10.1007/s00464-006-0136-y.

Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons.

BACKGROUND: The postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States. METHODS: A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC. RESULTS: Only 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice. CONCLUSIONS: Surveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

BACKGROUND: Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. METHODS: The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure. RESULTS: A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. CONCLUSION: A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease.

BACKGROUND: There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD). METHODS: A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: 7 months. RESULTS: From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians.

OBJECTIVE: Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA. METHODS: After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years. RESULTS: From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2). CONCLUSION: IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.

Quality of life after colectomy for colonic inertia.

BACKGROUND: Total abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long-term health related quality of life in these patients in relation to their functional outcome. METHODS: A consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was health-related quality of life assessed at follow-up using the SF-36 Health Survey. RESULTS: A total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3+/-27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7+/-2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF-36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations. CONCLUSIONS: After TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty.

BACKGROUND: The management of full thickness rectal prolapse remains controversial. Although abdominal approaches have a lower recurrence rate than do perineal operations, they are associated with a higher morbidity. The aim of this study was to compare the outcomes of perineal rectosigmoidectomy with and without levatorplasty. METHODS: Between 1989 and 1999, a total of 109 consecutive patients (10 men) underwent 120 perineal procedures. These patients were retrospectively evaluated in two groups on the basis of the type of surgery received: perineal rectosigmoidectomy (PRS) or perineal rectosigmoidectomy with levatorplasty (PRSL). Subsequent functional outcome and physiological parameters were assessed. RESULTS: The patients had a mean age of 75.7 years (range, 23.0-94.8 years) and they were followed for an overall mean (in both groups combined) of 28.0 months (range, 0.4-126.4 months) after surgery. Mean duration of surgery was 78.1 min (SD=25.9) and 97.6 min (SD=32.3) in PRS and PRSL, respectively ( p=0.002, unpaired t test). There was no significant difference between the two groups in terms of hospital stay, morbidity or mortality. Recurrence rates and mean time interval to recurrence were, respectively, 20.6% and 45.5 months in PRS compared to 7.7% and 13.3 months in PRSL ( p=0.049, chi-square test; p=0.001, unpaired t test). Both groups had significant improvements in postoperative incontinence score ( p<0.0001, Wilcoxon's matched-pairs signed-ranks test), however, there were no significant changes in anorectal manometric findings and pudendal nerve terminal motor latency assessment. CONCLUSIONS: Perineal rectosigmoidectomy with levatorplasty is associated with a lower recurrence rate and a longer time to recurrence than perineal rectosigmoidectomy alone. Levatorplasty should be offered to patients when a perineal approach for rectal prolapse is selected.

High compliance rates observed for follow up colonoscopy post polypectomy are achievable outside of clinical trials: efficacy of polypectomy is not reduced by low compliance for follow up.

INTRODUCTION: The National Polyp Study demonstrated that removal of adenomas with at least a three-year follow up reduced the incidence of colorectal cancer. However, compliance with follow up colonoscopy may affect the estimates of reduction in colorectal cancer incidence demonstrated by the National Polyp Study. While an 80% compliance rate for follow up colonoscopy was achieved during the National Polyp Study, the compliance rate for follow up colonoscopy is unknown in the general population. The aim of this study was to determine the compliance rate for follow up colonoscopy and factors which affect follow up. METHODS: A retrospective medical record review to identify patients who had adenomatous polyps excised in 1997 was undertaken. Patients who had inflammatory bowel disease, a prior history of colorectal cancer, familial adenomatous polyposis syndrome, colonic surgery; incomplete polypectomy or incomplete colonoscopy, and those patients who died before planned follow up, were excluded from analysis. Follow up was performed by telephone survey. RESULTS: Three hundred and thirty-three patients were identified (196 males; 147 females) with a mean age of 70 years. Three hundred and thirty-one (99%) of 333 had a documented recommendation for follow up of three years or less. Thirty-four percent (113 of 333) had previously undergone colonoscopy; 29% (98 of 333) had previously undergone polypectomy and 54% (180 of 333) were symptomatic at the time of the colonoscopy. Twenty-eight percent (40 of 141) had a family history of colorectal cancer. Pathology at polypectomy included a single polyp and polyps less than 10 mm in 68% and 88% of cases, respectively. Follow up was available in 211 of these cases, 179 (85%) of which had been compliant with follow up colonoscopy. In a univariate analysis, previous colonoscopy (P = 0.035), previous polyps (P = 0.043), asymptomatic status at time of colonoscopy (P = 0.021), polyp size (P = 0.008) and number of polyps (P = 0.010) were significantly associated with patients who were compliant with follow up colonoscopy. A multivariate logistics regression analysis revealed number of polyps (P = 0.036) and polyp size (P = 0.045) to be statistically significantly associated with compliance. CONCLUSION: Compliance with follow up colonoscopy after polypectomy is greater than 80%, regardless of age, education, family history, prior colonoscopy, or prior polypectomy. Risk reduction published in the National Polyp Study may likely reflect what can be achieved through the general use of colonoscopy for surveillance.

The effect of diverticular disease on the colonic J pouch.

OBJECTIVE: The aim of this study was to assess the impact of the diverticular disease (DD) on function and on postoperative complications of the colonic J-pouch (CJP) with pouch-anal anastomosis. METHODS: Patients who underwent a CJP between December 1990 and August 2001, were retrospectively reviewed. The presence of DD in the CJP was assessed on pouchogram prior to ileostomy closure. A questionnaire designed to evaluate the degree of continence (total incontinence score (IS): 0 = worst, 20 = best) and pouch evacuation (total evacuation score (ES): 0 = worst, 28 = best) was used for comparison between patients with DD and those without DD (NDD). RESULTS: Sixty-six patients (47 males; 19 females) with a median age of 68 years (range 28-87 years) were included. The median follow-up period was 22 months (range 2-106 months). Twenty-four patients comprised the DD group and 42 were in the NDD group. The two groups were comparable for age, gender and time from ileostomy closure; all patients with postoperative chemoradiation therapy were in the NDD group. The total ES and IS total did not significantly differ between the two groups with a P-value of 0.11 and 0.09 respectively. Furthermore, there was no significant difference in the total incidence of pouch complications between the two groups (3 strictures, 1 leak, 1 fistula in the NDD group vs. 1 pelvic sepsis in the DD group; P = 0.4). CONCLUSIONS: The presence of DD in a CJP does not seem to impact pouch function or the postoperative complication rate.

Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

INTRODUCTION: Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis. METHODS: All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed. RESULTS: Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients. CONCLUSION: Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.