Laparoscopic surgery in the management of inflammatory bowel disease.

BACKGROUND: The role of laparoscopic surgery in the treatment of various upper and lower gastrointestinal disorders is still under investigation. However, a variety of laparoscopic procedures may be applied in the treatment of inflammatory bowel disease (IBD). PATIENTS AND METHODS: We present our initial results of laparoscopic and laparoscopic-assisted management of IBD in 72 consecutive patients (37 women and 35 men; mean age 36 years, range 20 to 79). The indications for surgery included: terminal ileitis in 29 patients, mucosal ulcerative colitis in 23 patients, Crohn's colitis in 11 patients, severe perianal Crohn's disease in 4 patients, duodenal Crohn's disease in 3 patients, Crohn's rectovaginal fistula in 1 patient, and rectourethral fistula in 1 patient. The procedures performed included: total abdominal colectomy (TAC) in 30 patients (22 with total proctocolectomy with ileoanal reservoir, 6 with TAC with ileorectal anastomosis, and 2 with TAC with end ileostomy), ileocolic resection in 30 patients, diverting loop ileostomy in 6 patients, closure of an end ileostomy as an ileorectal anastomosis in 3 patients who already underwent a TAC with end ileostomy, and duodenal bypass gastrojejunostomy in 3 patients. RESULTS: There were 16 complications in 13 (18%) patients: 3 enterotomies, 4 episodes of bleeding, 3 pelvic abscesses, 2 intestinal obstructions, 2 prolonged ileus, 1 anastomotic leak, and 1 efferent loop obstruction after gastrojejunostomy. However, only 3 patients required laparotomy for morbidity, and there was no mortality. In 7 (10%) patients, the laparoscopic procedure was converted to a laparotomy due to a large inflammatory mass with fistula in 4 patients, bleeding in 2 patients, and an enterotomy in 1 patient. The mean operating time was 2.9 hours (range 0.7 to 6) and the mean length of hospital stay was 6.5 days (range 3 to 19). When compared with ileocolic resection, total colectomy was associated with higher morbidity (30% versus 10%, P < 0.05) and longer hospitalization (8.7 days [range 4 to 19] versus 5.2 days [range 3 to 7], respectively; P < 0.05). CONCLUSIONS: According to this initial experience, laparoscopic surgery is a versatile and effective modality in the surgical management of inflammatory bowel disease in selected patients. However, laparoscopic total colectomy is associated with higher morbidity when compared with ileocolic resection.

Recovery of anal sphincter function after the ileoanal reservoir procedure in patients over the age of fifty.

PURPOSE: This study was undertaken to postoperatively assess the progression of anal sphincter function and clinical outcome in patients > or = 50 years old (Group I) compared with those < 50 years old (Group II). METHODS: Clinical data were assessed after ileostomy closure by a questionnaire. These data were compiled to obtain an incontinence score, which ranged from 0 (perfect continence) to 20 (total incontinence). Anorectal manometry was performed preoperatively (MN1) and postoperatively, before (MN2) and after (MN3) ileostomy closure. Wilcoxon and paired t-test were used to compare the clinical and functional results, respectively. RESULTS: Group I consisted of 22 patients (mean age, 56 years) and Group II, 50 patients (mean age, 32 years). No differences were found relative to either preoperative pressures or clinical outcome. However, both the mean and high resting pressures were significantly lower in Group I at the MN2 examination. CONCLUSION: The effect on anal sphincters of ileoanal reservoir in patients over the age of 50 years is similar to that noted in younger patients. Transient impairment of internal anal sphincter function observed after ileoanal reservoir is more severe in older patients (P = 0.01). However, as in younger patients, it does completely recover after ileostomy closure.

Does laparoscopic-assisted ileal pouch anal anastomosis reduce the length of hospitalization?

Previous data have suggested that laparoscopic colon and rectal surgery may shorten the length of hospitalization. These claims have been attributed to a reduction of the length of ileus. The definition of "ileus" is variable and in all cases is subjective. In this study it was defined as the length of time until the patient passed flatus or stool without nausea, vomiting or abdominal distention. This prospective study was undertaken to compare the duration of ileus and of hospitalization after laparoscopic-assisted (LAC) and standard laparotomy (SC). After restorative proctocolectomy with an ileal-pouch anal anastomosis (IPAA) in both sets of patients. Twenty-two patients underwent LAC and 20 age, sex, and diagnosis-matched controls underwent SC. Mucosal ulcerative colitis (MUC) was the diagnosis in 16 LAC and in 15 SC patients while polyposis was the diagnosis in 6 LAC and in 5 SC patients. The mean time to resolution of postoperative ileus was 4.2 (4-11) days in the LAC group and 3.3 (2-5) days in the SC group. Hospital discharge was similar in each group occurring at a mean of 8.7 (7-13) days after LAC and 8.9 (6-18) days after SC. Neither the length of time for ileus resolution nor the length of hospitalization were reduced in the LAC group. Laparoscopic-assisted IPAA conferred none of the theoretical advantages associated with other laparoscopic procedures.

Optimization of sphincter function after the ileoanal reservoir procedure. A prospective, randomized trial.

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: high-pressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17-69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (delta = 2.6) in Group 1 and from 0.2 to 2.0 (delta = 1.8) in Group 2 (P = 0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P > 0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.

Ileal pouch-anal anastomosis: is preoperative anal manometry predictive of postoperative functional outcome?

PURPOSE: The aim of this study was to determine the value of preoperative anal manometry in predicting post-operative continence. METHODS: Anal manometry was performed in 73 consecutive patients before ileal pouch-anal anastomosis (IPAA) surgery (m1), before loop ileostomy closure (m2), and at a follow-up of one (m3) and two (m4) years. Mean and maximum resting and squeezing pressures were documented at each occasion. One year after surgery, pressures were correlated (r) with an incontinence score. RESULTS: A significant (P < 0.05) decrease in mean resting pressures was observed after IPAA (m1 = 66 mmHg; m2 = 42.8 mmHg), followed by a significant (P < 0.05) improvement of mean resting pressure after loop ileostomy closure (m3 = 53.8 mmHg; m4 = 54.7 mmHg). Mean squeezing pressures did not change (P > 0.05) at any time during the study (m1 = 114 mmHg; m2 = 102.9 mmHg; m3 = 103.4 mmHg; m4 = 95.8 mmHg). There was no correlation between preoperative mean resting pressure and postoperative (mI) incontinence score. CONCLUSION: Anal manometry showed a characteristic trend in internal anal sphincter injury after IPAA followed by recovery after ileostomy closure. However, it failed to prove helpful in the prediction of clinical outcome. Thus, although this study supports the continued use of manometry in a research setting, it challenges the value of routine manometry in a clinical context.

An initial comparative study of two techniques of laparoscopic colonic anastomosis and mesenteric defect closure.

Laparoscopic colon and rectal surgery is still in its nascent stages of development. The ease, efficacy, and safety of intracorporeal mechanical colonic anastomosis are contingent upon expensive stapling devices. Although mobilization and mesenteric division are feasible, a method of inexpensive rapid anastomosis is not. A single inexpensive multifire stapler which could be used both to fashion the anastomosis and to close the mesenteric defect would be ideal. Therefore, this prospective randomized study was undertaken to compare the clinical and functional results of laparoscopic colotomy closure performed using the Endopath EMS hernia stapler (EMS; Ethicon Endosurgery Inc., Cincinnati, OH) to results of using standard two-layer hand suturing (HS). Both the colotomy itself and the mesenteric defect closure sites were included in the randomization and analysis. The abdominal cavity was assessed for evidence of anastomotic leakage, abscess, and adhesion formation. In addition, radiographic luminal diameter, bursting strength, and histology were evaluated. Eight healthy pigs were randomized to either the EMS (N = 4) or HS (N = 4). There was no evidence of leakage, abscesses, or adhesion formation in either group; however, the mesenteric defect revealed more scarring in the HS than in the EMS animals. There were no significant differences in either luminal diameter (HS: mean = 0.92 cm; EMS: mean = 0.91 cm) or bursting strength (HS: mean = 171 mm Hg; EMS: mean = 157 mm Hg) (P > 0.05). Histologic analysis also demonstrated no difference in inflammation, necrosis, or fibrosis. This study suggests that this technique can be safely applied to both colotomy closure and mesenteric defect repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Anal endosonography for recurrent anal fistulas: image enhancement with hydrogen peroxide.

Anal endosonography is a new technique that is useful in the preoperative assessment of patients with anal fistulas. Endosonographic images are created by the reflection of sound waves from the interfaces between tissues of varying densities. In order to accentuate tissue interface layers at the level of the fistula tract, we introduced hydrogen peroxide into the fistula tract through the external opening during anal ultrasonography in two patients with recurrent anal fistula. Hydrogen peroxide injection resulted in hyperechoic imaging of the preinjection hypoechoic horseshoe fistula tract. Endosonographic findings were confirmed at the time of surgery in both patients. We conclude that hydrogen peroxide enhancement of the fistula tract is a simple, effective, and safe method of improving the accuracy of endoanal ultrasound assessment of recurrent anal fistula.

Laparoscopic colorectal surgery: a prospective assessment and current perspective.

Between August 1991 and June 1993, 74 laparoscopic and laparoscopically assisted colonic and rectal operations were performed. A variety of procedures were carried out including 32 total abdominal colectomies (group 1), 32 segmental resections (group 2) and ten constructions of a diverting stoma without formal resection (group 3). Indications for surgery were mucosal ulcerative colitis in 20 patients, carcinoma in 12, polyposis in six, Crohn's disease in seven and other conditions in the remaining 29. The 74 comprised 42 male and 32 female patients of mean age 45 (range 12-88) years. The median (range) duration of the procedure was 3.0 (1.0-6.5) h for the entire group, 3.9 (2.5-6.5) h for group 1, 2.9 (1.5-5.5) h for group 2 and 1.8 (1.0-2.5) h for group 3. The median (range) length of ileus was 3.0 (2-7) days overall; respective times for groups 1-3 were 3.5 (2-7), 3.0 (2-7) and 2.0 (1-4) days. The median (range) length of hospitalization was 7.0 (2-40) days, 8.1 (4-19) days in group 1, 7.0 (4-20) days in group 2 and 6.0 (2-40) days in group 3. Ten patients (14 per cent) developed intraoperative and 15 (20 per cent) postoperative complications; there were no deaths. These results failed to confirm any significant advantages of laparoscopic or laparoscopically assisted colorectal surgery. Specifically, neither the operating time, nor length of ileus, nor length of hospitalization was improved over standard procedures. Advances in technology and surgical technique may improve such findings in the future.

Perineal rectosigmoidectomy in the elderly.

Between April 1989 and October 1991, 20 consecutive patients underwent perineal rectosigmoidectomy and coloanal anastomosis for full-thickness rectal prolapse. These 16 females and 4 males, with a mean age of 82 (range, 68-101) years, were evaluated by detailed functional assessment and physiologic testing. A grading scale from 0 to 24 was based upon the frequency and type of incontinence, 0 representing full continence. The mean preoperative continence score was 14.5, while the mean postoperative continence score was 8.4. The mean length of resected rectosigmoid was 23 cm. There was one postoperative death and one significant complication, a postoperative pelvic hematoma that required reoperation. There were no full-thickness recurrences at a mean follow-up of 26 months. Six of the 10 patients who underwent preoperative pudendal nerve terminal motor latency (PNTML) testing had evidence of severe neuropathy (latencies greater than 2.5 milliseconds). Prolonged PNTML, however, was not shown to be an accurate predictor of postoperative incontinence because four of the six patients with neuropathy regained excellent to good control. In conclusion, perineal rectosigmoidectomy is a safe operation for the treatment of full-thickness rectal prolapse in the elderly patient. Improved postoperative continence was noted in 90 percent of patients, with improvement seen even in those patients with severe pudendal neuropathy.

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

Does perineal descent correlate with pudendal neuropathy?

A prospective study was undertaken to assess the potential correlation between increased perineal descent (IPD) and pudendal neuropathy (PN) in 213 consecutive patients. These 165 females and 48 males of a mean age of 62 (range, 18-87) years had constipation (n = 115), idiopathic fecal incontinence (n = 58), or chronic intractable rectal pain (n = 40). All 213 patients underwent cinedefecography (CD) and bilateral pudendal nerve terminal motor latency (PNTML) assessment. Perineal descent (PD) of more than the upper limit of normal of 3.0 cm during evacuation was considered increased. Pudendal neuropathy was diagnosed when PNTML exceeded the upper limit of normal of 2.2 milliseconds. Although 65 patients (31 percent) had PD, only 16 (25 percent) of these 65 patients had neuropathy. Moreover, PN was also found in 42 (28 percent) of 148 patients without IPD. Conversely, only 16 (28 percent) of the 58 patients who had PN also had IPD, and IPD was present in 49 (32 percent) of 155 patients without PN. The frequency of PN according to the degree of IPD was: 3.0 to 4.0 cm, 6 of 27 patients (22 percent); 4.1 to 5.0 cm, 4 of 15 (27 percent); 5.1 to 6.0 cm, 4 of 12 (25 percent); 6.1 to 7.0 cm, 2 of 8 (25 percent); and > 7.0 cm, 0 of 3 (0 percent). Linear regression analysis was undertaken to compare the relationships between measurements of PD at rest (R), push (P), and change (C = P-R) and values of PNTML. These values for all 213 patients were: R, r = 0.048; P, r = 0.031; and C, r = -0.050. The correlation coefficients were equally poor for all the individual subgroups analyzed, including the patient's sex or diagnosis. In summary, no correlation was found between PD and PNTML. The lack of a relationship was seen for the entire group as well as for those patients with either neuropathy or increased perineal descent. Therefore, the often espoused relationship between increased PD and PN was not supported by this prospective evaluation. Although increased PD and prolonged PNTML are frequently observed in patients with disordered defecation, they may represent independent findings.

Loop ileostomy is a safe option for fecal diversion.

This study was undertaken to prospectively assess all morbidity and mortality associated with temporary loop ileostomy. Eighty-three consecutive patients of a median age of 45 years required temporary fecal diversion after either ileoanal or low colorectal anastomosis (n = 72), for perianal Crohn's disease (n = 5), or for other reasons (n = 6). All loop ileostomies were supported with a rod, and fecal diversion was maintained for a mean of 10 weeks. To date, 67 patients have had re-establishment of intestinal continuity. Stoma closure was affected through a parastomal incision in 64 patients; in three, a laparotomy was required. The closure was stapled side to side in 49 patients, while a hand-sewn anastomosis was done in the other 18 patients; all skin wounds were left open. The mean length of surgery for ileostomy closure was 56 minutes, and the mean hospital stay was five days. Nine patients (10.8 percent) developed 10 complications, nine of which required hospitalization. Specifically, four patients developed dehydration and electrolyte abnormalities secondary to high stoma output, and two had anastomotic leaks that spontaneously healed following conservative management. One patient developed a superficial wound infection that spontaneously drained itself. One patient developed a partial small bowel obstruction that resolved without surgery after a four-day hospitalization. One stoma retracted after supporting rod removal and prompted premature closure. There was no stomal ischemia, hemorrhage, prolapse, or mortality in this series. Thus, loop ileostomy is a safe way to achieve fecal diversion.

Is aggressive management of perianal ulcers in homosexual HIV-seropositive men justified?

A study was undertaken to assess the etiology, optimal diagnostic method, and incidence of healing of perianal ulcers in HIV-seropositive men. Between March 1990 and December 1991, 26 HIV-seropositive homosexual or bisexual males were referred with perianal ulcerations. According to CDC criteria, three (12 percent) were Class II, six (23 percent) were Class III, and 17 (65 percent) were Class IV. Eighteen patients had one ulcer, five had two ulcers, and two had three ulcers. In one patient the ulcer was circumanal. Patients with superficial erosions were not included. Biopsies were obtained in 23 patients for routine microscopy, HIV, cytomegalovirus, herpes simplex virus, and acid-fast bacilli. Biopsy revealed an immunoblastic lymphoma in one patient. A comparison of microscopy and culture results revealed culture to be more helpful in determining the etiology of these ulcers. Medical treatment included reverse transcriptase inhibitors (zidovudine, dideoxyinosine, and dideoxycytosine), oral and topical Zovirax (Burroughs Wellcome, Research Triangle Park, NC), ganciclovir, and oral broad-spectrum antibiotics. Surgical treatment included lateral internal sphincterotomy in three patients and seton placement in one patient. Follow-up for at least four weeks was obtained in 22 patients. Overall, healing occurred in 15 patients (68 percent): three (20 percent) were Class II, four (27 percent) were Class III, and eight (53 percent) were Class IV. Healing occurred in all four patients who underwent surgical treatment. In conclusion, aggressive diagnostic maneuvers allow the use of both medical and conservative surgical measures to successfully treat the majority of perianal ulcers in this patient population.

Principles of surgical resection. Influence of surgical technique on treatment outcome.

In the absence of curative medical therapy, surgical resection remains the cornerstone of treatment for patients with colorectal carcinoma. A thorough knowledge of colon and rectal anatomy is crucial for the formulation of an effective operative strategy. There are certain technical factors under the control of the surgeon that may have prognostic significance for the patient. These include the length of the distal margin of resection, the use of intraluminal cytotoxic solutions to reduce the viability of exfoliated cancer cells, and the technique of colon anastomosis. Curative resections should include removal of the lymphatic drainage of the tumor-bearing segment of colon. When there is adjacent organ invasion by the colonic primary, en block resection of the entire tumor mass with adequate margins is the procedure of choice. Prophylactic oophorectomy in women with colon carcinoma remains controversial. The effects of perioperative transfusion on tumor behavior remain unclear. Blood transfusions should be administered only when there is a specific medical necessity.

Evaluation and treatment of chronic intractable rectal pain--a frustrating endeavor.

A study was undertaken to assess the evaluation and treatment of chronic intractable rectal pain. Sixty consecutive patients, 23 males and 37 females with a mean age of 69 (range, 29-87) years and a mean length of symptoms of 4.5 years, were evaluated by questionnaire, office examination, anal manometry, electromyography, cinedefecography, and pudendal nerve study. In all cases, organic abdominopelvic and anorectal etiologies for the pain were excluded by extensive radiologic and endoscopic evaluation. All patients had failed conservative and medical therapy. Ninety-five percent of patients had one or more associated factors: constipation or dyschezia (57 percent), prior pelvic surgery (43 percent), prior anal surgery (32 percent), prior spinal surgery (8 percent), irritable bowel syndrome (10 percent), or psychiatric disorders (depression or anxiety; 25 percent). Possible etiologies for the pain included levator spasm or anismus in 62 percent, coccygodynia in 8 percent, and pudendal neuropathy in 24 percent of patients. Therapy for pain control included electrogalvanic stimulation (EGS) in 29, biofeedback (BF) in 14, and steroid caudal block (SCB) in 11 patients. Pain control was assessed by an independent observer at a mean of 15 (range, 2-36) months after completion of therapy. Continued successful pain relief was classified by patients as good or excellent after EGS in 38 percent, after BF in 43 percent, and after SCB in 18 percent; overall success was reported by 47 percent of patients. The presence of levator spasm, coccygodynia, or pudendal neuropathy did not influence outcome. The routine use of physiologic investigation of rectal pain may not be justifiable. Moreover, more than half of the patients were refractory to all three therapeutic options used in this study.

Laparoscopic colectomy: a critical appraisal.

A multicenter retrospective study was undertaken to assess the efficacy and safety of laparoscopy in colon and rectal surgery. To minimize potential bias in interpretation of the results, all data were registered with an independent observer, who did not participate in any of the surgical procedures. Sixty-six patients underwent a laparoscopic procedure. Operations performed included sigmoid colectomy (19), right hemicolectomy (15), low anterior resection (6), colectomy with ileal pouch-anal anastomosis (IPAA) (5), and abdominoperineal resection (APR) (3). The conversion rate from laparoscopic colectomy to celiotomy was 41 percent. Major morbidity and mortality were 24 percent and 0 percent, respectively. Length of stay, hospital costs, and lymph node harvest were compared between the sigmoid resection and right hemicolectomy subgroups. Data from traditional sigmoid colectomies and right hemicolectomies were obtained from the same institutions for comparison. Mean postoperative stay for laparoscopically completed sigmoid and right colectomies was significantly less than that for either the converted or the traditional groups (P < 0.02). Total hospital cost for traditional right hemicolectomy was significantly less than that for the converted group (P < 0.05) but not the laparoscopic group. Laparoscopic sigmoid resection showed no significant total hospital cost difference among traditional, converted, and laparoscopic groups. Lymph node harvest in resections for carcinoma was comparable in all groups. These preliminary data suggest that laparoscopic colon and rectal surgery can be accomplished with acceptable morbidity and mortality when performed by trained surgeons. Length of stay is shorter, but there is no proven total hospital cost benefit. Appropriate registries will be necessary to adequately assess long-term outcome.

Gastroduodenal polyps in patients with familial adenomatous polyposis.

A review of the endoscopy reports and pathology results from esophagogastroduodenoscopy (EGD) of all patients with familial adenomatous polyposis (FAP) undergoing such an examination was performed. Two hundred forty-seven patients were identified, with an overall prevalence of duodenal adenomas of 66 percent and of fundic gland polyps of 61 percent. Analysis of our more recent experience (1986 to 1990) shows the prevalence to be 88 percent and 84 percent, respectively. A normal-appearing papilla was adenomatous in 50 percent of cases. No case of periampullary carcinoma developed in patients under surveillance. Routine EGD is indicated for patients with FAP. Duodenal adenomas and fundic gland polyps will occur in the majority of patients.

Toxic colitis: diagnosis and management.

Toxic colitis, a serious complication of ulcerative colitis and Crohn's disease, may be life threatening. Early diagnosis and ensuing intensive medical therapy may control the disease process. Lack of rapid response to medical therapy necessitates surgical intervention. Subtotal colectomy and ileostomy is the operative procedure of choice. This allows resolution of the disease process and does not destroy the options for restorative operation at a later date.

Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis.

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after double-stapled ileoanal reservoir (IAR) for mucosal ulcerative colitis (MUC). Between September 1988 and February 1992, 56 patients with MUC underwent an IAR. Forty-five patients had a double-stapled IAR (DS-IAR), seven patients had a transanal pursestring stapled IAR (PS-IAR), and four patients had a PS-IAR with mucosectomy. Distal donuts obtained from the stapled IAR were submitted for pathologic review in 55 patients. Nine patients had only small bowel, connective tissue, and/or muscle noted on review. Mucosa was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE). All samples were examined for evidence of inflammation and dysplasia. Four patients had SE only, one patient had TE, and 18 had CE. In addition, three patients had SE and CE, seven patients had SE and TE, two patients had CE and TE, and nine patients had all three types. The distance from the dentate line to the anastomosis ranged from 0 to 2.5 cm (mean, 1 cm). In 19 patients (35 percent), the distal donut revealed MUC. Of these 19 patients, six had persistent MUC (43 percent) at the time of subsequent biopsy. An additional four patients had MUC evident on follow-up biopsy but not on distal donuts; two of these four patients had no mucosa in their distal donuts. Only one of the patients with evidence of MUC on donuts and/or biopsy experienced any symptoms referable to active MUC (1.8 percent). None of the specimens examined had any evidence of dysplasia. In 31 patients, no MUC was present in the initial donuts or follow-up biopsies. Although the double-stapled technique appears safe, periodic monitoring is suggested.

Laparoscopic total abdominal colectomy. A prospective trial.

The aim of this study was to prospectively assess the impact of laparoscopy upon the outcome of total abdominal colectomy (TAC). Specifically, patients underwent standard laparotomy with TAC and ileoproctostomy (TAC + IP), TAC and ileoanal reservoir (TAC + IAR), laparoscopically assisted TAC + IP (L-TAC + IP), or laparoscopically assisted TAC + IAR (L-TAC + IAR). Parameters studied included the length of surgery, length of ileus, length of hospitalization, morbidity, and mortality. Five patients underwent standard TAC (Group I), and five underwent L-TAC (Group II). Group I consisted of five patients of a mean age of 32 (range, 24-51) years who had mucosal ulcerative colitis (n = 1), familial adenomatous polyposis (n = 3), or colonic inertia (n = 1). Group II consisted of five patients of a mean age of 33 (range, 17-43) years who had mucosal ulcerative colitis (n = 1), familial adenomatous polyposis (n = 3), or colonic inertia (n = 1). This preliminary prospective study indicates that laparoscopically assisted TAC is feasible. L-TAC resulted in a slightly longer length of ileus and length of hospitalization; these differences were not statistically significant. Moreover, the length of time required for the laparoscopic procedures was 35 percent longer than for the open procedures. Although these results may improve as more cases are performed, dramatic differences in rates of postoperative recovery have not yet been realized. In conclusion, L-TAC, while technically feasible, dose not appear to offer any immediately recognizable benefits to the patient as compared with standard laparotomy.