End-to-end stapled technique for Kono-S anastomosis

PURPOSE

Our aim was to develop a Kono-S anastomotic technique using surgical staplers.

METHODS

Two patients underwent stapled Kono-S anastomosis, one via abdominal and one transanal approach.

RESULTS

The approach for an abdominal and transanal stapled Kono-S anastomosis is detailed.

CONCLUSION

The Kono-S anastomosis can be safely configured using common surgical staplers.

Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease

BACKGROUND

In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD.

METHODS

A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes.

RESULTS

The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042).

CONCLUSION

Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

Infliximab in the treatment of medically refractory indeterminate colitis

AIM

To examine the outcome of infliximab intervention in refractory indeterminate colitis.

METHODS

Twenty patients with severe, medically refractory indeterminate colitis were treated with infliximab. All patients initially received infliximab, 5 mg/kg, intravenously and, in some patients, the dose was subsequently increased to 10 mg/kg. The number of infusions ranged from one to 16 per patient. Indeterminate colitis was defined as colitis that could not be classified with certainty as Crohn's disease or ulcerative colitis based on traditional clinical, endoscopic and histopathological criteria. The clinical response to infliximab was classified as complete response, partial response or non-response.

RESULTS

Fourteen of the 20 patients (70%) showed a complete response to infliximab treatment, two showed a partial response and four showed no response. The four non-responders underwent colectomy with ileal pouch-anal anastomosis. The resected colon specimen was consistent with ulcerative colitis in all four cases, although two were subsequently re-classified as Crohn's disease. Eight additional patients were subsequently re-classified as having Crohn's disease on longer follow-up evaluation, whilst eight continued to have features of indeterminate colitis. The response rate to infliximab treatment was similar in both groups.

CONCLUSIONS

Infliximab is effective in approximately two-thirds of patients with indeterminate colitis, and thus may be considered for patients with refractory disease prior to colectomy. The follow-up time afforded by infliximab treatment may allow for more accurate classification of the disease in a significant proportion of patients whose colitis has indeterminate features at initial presentation.

High level perinuclear antineutrophil cytoplasmic antibody (pANCA) in ulcerative colitis patients before colectomy predicts the development of chronic pouchitis after ileal pouch-anal anastomosis

BACKGROUND

The reported cumulative risk of developing pouchitis in ulcerative colitis (UC) patients undergoing ileal pouch-anal anastomosis (IPAA) approaches 50% after 10 years. To date, no preoperative serological predictor of pouchitis has been found.

AIMS

To assess whether preoperative perinuclear antineutrophil cytoplasmic antibody (pANCA) expression was associated with acute and/or chronic pouchitis after IPAA.

METHODS

Patients were prospectively assessed for the development of clinically and endoscopically proved pouchitis. Serum obtained at the time of colectomy in 95 UC patients undergoing IPAA was analysed for pANCA by ELISA and indirect immunofluorescence. pANCA+ patients were stratified into high level (>100 ELISA units (EU)/ml) (n=9), moderate level (40-100 EU/ml) (n=32), and low level (<40 EU/ml) (n=19) subgroups.

RESULTS

Sixty of the 95 patients (63%) expressed pANCA. After a median follow up of 32 months (range 1-89), 32 patients (34%) developed either acute (n=14) or chronic (n=18) pouchitis. Pouchitis was seen in 42% of pANCA+ patients compared with 20% of pANCA- patients (p=0.09). There was no significant difference in the incidence of acute pouchitis between the three pANCA+ patient subgroups. The cumulative risk of developing chronic pouchitis among patients with high level pANCA (56%) before colectomy was significantly higher than in patients with medium level (22%), low level (16%), and those who were pANCA- (20%) (p=0.005). Multivariate analysis revealed that the sole parameter significantly associated with the development of chronic pouchitis after IPAA was the presence of high level pANCA before colectomy (p=0.005).

CONCLUSION

High level pANCA before colectomy is significantly associated with the development of chronic pouchitis after IPAA.

Rubber band ligation for hemorrhoidal disease can be safely performed in select HIV-positive patients

PURPOSE

Many surgeons have abandoned the use of rubber band ligation for the treatment of hemorrhoids in patients infected with human immunodeficiency virus because of the belief that this procedure could lead to disastrous outcomes. This study was designed to evaluate the safety and efficacy of rubber band ligation in otherwise healthy human immunodeficiency virus-positive patients.

METHODS

A retrospective chart review of healthy human immunodeficiency virus-positive patients who underwent rubber band ligation for symptomatic hemorrhoids between April 1993 and May 2000 was conducted.

RESULTS

The study group comprised 11 patients. All patients were male, with a median age of 48 (range, 32-64) years. Mean T-cell helper count was 450 (range, 200-1,000) cells/microl. A median of 2 (range, 1-4) rubber band ligations were performed per patient. The median length of follow-up was seven (range, 1-28) months. There were no deaths or complications in any study group patient. Eight patients (73 percent) had excellent results, with complete resolution of symptoms. Two patients (18 percent) had initial improvement but subsequently had hemorrhoidectomy because of recurrent symptoms. Only one patient (9 percent) had no benefit from rubber band ligation and underwent hemorrhoidectomy.

CONCLUSION

These data suggest that asymptomatic human immunodeficiency virus-positive patients can be treated safely and effectively with rubber band ligation for symptomatic hemorrhoids.

Crohn's disease-associated genetic marker is seen in medically unresponsive ulcerative colitis patients and may be associated with pouch-specific complications

PURPOSE

Genetic markers have been used to define subgroups of patients within the broad categories of Crohn's disease and ulcerative colitis that may differ in clinical course and response to medical therapy. The tumor necrosis factor microsatellite haplotype a2blc2d4e1 has been found previously to be present in 24 percent of patients with Crohn's disease and only 5 percent of patients with ulcerative colitis. This study examined associations between this microsatellite haplotype and the postoperative clinical course of patients with ulcerative colitis undergoing ileal pouch-anal anastomosis.

METHODS

As part of a large, controlled, prospective study to correlate genetic markers with clinical phenotypes, tumor necrosis factor microsatellite alleles at five loci (a, b, c, d, and e) were determined from genomic DNA by polymerase chain reaction in 32 patients with a clinical and histopathologic diagnosis of ulcerative colitis who underwent ileal pouch-anal anastomosis for medically unresponsive disease. All patients with ileal pouch-anal anastomosis were also studied prospectively for pouch-specific complications.

RESULTS

The tumor necrosis factor haplotype a2blc2d4e1 was present in 11 patients. Median follow-up was 19 months. Thirteen patients had a pouch-specific complication (12 pouchitis and 1 pouch-perineal fistula). Six of 11 patients (55 percent) with the haplotype had a pouch-specific complication compared with 7 of the 21 patients (33 percent) who did not possess this haplotype (P = 0.22). Median time from surgery to pouch-specific complication was eight months. Patients with the haplotype had a median time to pouch-specific complication of three months, whereas patients without the haplotype had a median time of 11 months (P = 0.04). In addition, 36 percent of patients with the haplotype had chronic pouch complications vs. only 10 percent of patients without the haplotype (P = 0.05).

CONCLUSION

The Crohn's disease-associated tumor necrosis factor haplotype a2blc2d4e1 may define a subgroup of medically unresponsive patients with ulcerative colitis who are predisposed to a higher incidence of pouch-specific complications after ileal pouch-anal anastomosis.

Does HIV status influence the anatomy of anal fistulas?

PURPOSE

Although anorectal disease is common in human immunodeficiency virus-positive patients, little is known about the type and anatomic distribution of anal fistulas in this patient group. The aim of this study was to compare anatomic characteristics of anal fistulas in human immunodeficiency virus-positive patients with those in human immunodeficiency virus-negative patients by use of a retrospective chart review.

METHODS

The charts of 146 male patients younger than 50 years with an anal fistula were reviewed. Incomplete fistulas referred to those tracts arising from an internal opening into either a blind sinus or an undrained abscess cavity.

RESULTS

There were 60 human immunodeficiency virus-positive patients and 86 human immunodeficiency virus-negative patients. Mean age of the human immunodeficiency virus-positive patient group was 37 years vs. 40 years for the human immunodeficiency virus-negative patient group. Thirty-one human immunodeficiency virus-positive patients (52 percent) were classified as having AIDS, and the remaining 29 patients (48 percent) were asymptomatic. Mean T helper cell count in the human immunodeficiency virus-positive patient group was 277 cells per microliter. Fistulous tracts were intersphincteric (n = 56), transsphincteric (n = 41), suprasphincteric (n = 2), and incomplete (n = 47). Incomplete fistulas were identified in 33 (55 percent) human immunodeficiency virus-positive patients vs. 14 (16 percent) human immunodeficiency virus-negative patients (P < 0.001). Of the 47 incomplete fistulas, 37 (79 percent) were found in association with an abscess cavity. All ten patients with an incomplete fistula into a blind sinus were human immunodeficiency virus-positive. The incidence of an incomplete fistula without an abscess was significantly higher in the human immunodeficiency virus-positive patient group (17 percent) compared with the human immunodeficiency virus-negative patient group (0 percent; P < 0.001).

CONCLUSIONS

Anal fistulas in HIV-positive patients arise from the dentate line in similar locations to human immunodeficiency virus negative patients. However, human immunodeficiency virus-positive patients were more likely to have incomplete anal fistulas than human immunodeficiency virus-negative patients. Furthermore, human immunodeficiency virus-positive patients are predisposed to incomplete fistulas leading into a blind sinus.

Colorectal cancer: comparison of laparoscopic with open approaches

PURPOSE

We compared laparoscopic with open colectomy for treatment of colorectal cancer.

METHODS

We performed a retrospective review of patients undergoing colectomy for colorectal cancer between January 1991 and March 1996 at a large private metropolitan teaching hospital. Operative techniques included open (n=90) and laparoscopic (n=80) colectomy. Laparoscopic colectomy was further subdivided into the following groups: facilitated (n=62), with extracorporeal anastomosis; near-complete (n=9), with small incision for specimen delivery only; complete (n=3), with specimen removal through the rectum; and converted to an open procedure (n=6). Main outcome measures included operative time, blood loss, time to oral intake, length of postoperative hospitalization, morbidity, lymph node yield, recurrence, survival, and costs.

RESULTS

Operative time was equivalent in the laparoscopic and open groups (laparoscopic, 161 minutes; open, 163 minutes; P=0.94). Blood loss was less for the laparoscopic group (laparoscopic, 104 ml; open, 184 ml; P=0.001), and resumption of oral intake was earlier (laparoscopic, 3.9 days; open, 4.9 days; P=0.001), but length of hospitalization was similar. Mean lymph node yield in the laparoscopic group was 12 compared with 16 in the open group (P=0.16). Rates of morbidity, recurrence, and survival were similar in both groups. No port-site recurrences occurred.

CONCLUSIONS

Laparoscopic and open colectomy were therapeutically similar for treatment of colorectal cancer in terms of operative time, length of hospitalization, recurrence, and survival rates. The laparoscopic approach was superior in blood loss and resumption of oral intake.

Should HIV status alter indications for hemorrhoidectomy?

PURPOSE

There is a widespread belief that performing hemorrhoidectomy on a patient infected with human immunodeficiency virus (HIV) is an invitation for disaster. Aim of this study was to compare morbidity of hemorrhoidectomy in HIV-positive (HIV+) with HIV-negative (HIV-) patients.

METHODS

Charts of 27 HIV+ and 30 HIV- male patients less than age 50 years who underwent hemorrhoidectomy were reviewed.

RESULTS

Mean age of the 57 study group patients was 38 years. Open hemorrhoidectomy was performed in 26 patients (46 percent), and a closed technique was used in 31 patients (54 percent). HIV+ and HIV- patient groups were well matched to all preoperative and intraoperative variables. Mean T-cell helper count in the HIV+ patient group was 301 (range, 9-1,040) cells/microliter. There were no deaths, and complications were seen in 15 patients (26 percent). There was no difference in overall complication rates between HIV+ and HIV- patient groups. Urinary retention was seen in ten patients (18 percent), three of whom were HIV+ (11 percent) vs. seven of whom were HIV- (23 percent) (P = not significant). Although no patient required reoperation for bleeding, postoperative hemorrhage was seen in three patients (1 HIV+, 2 HIV-). None of the patients developed fecal incontinence. Mean time to complete wound healing was 6.8 (range, 4-12) weeks for HIV+ patients vs. 6.6 (range, 4-14) weeks for HIV- patients (P = not significant).

CONCLUSIONS

These data suggest that HIV status of a patient should not alter indications for surgical management of hemorrhoidal disease.

Morbidity of subtotal colectomy in patients with severe ulcerative colitis unresponsive to cyclosporin

PURPOSE

The aim of this study was to document the morbidity of urgent subtotal colectomy and ileostomy in patients with severe ulcerative colitis who failed cyclosporin treatment.

METHODS

We reviewed the charts of patients with severe ulcerative colitis who did not respond to cyclosporin treatment and underwent urgent subtotal colectomy and Brooke ileostomy at two inflammatory bowel disease centers over the 12-month period ending April 1994.

RESULTS

Fourteen patients (6 males; mean age, 34 years) required an urgent subtotal colectomy and Brooke ileostomy after failing treatment with cyclosporin. There were no deaths. Eight patients (57 percent) developed post-operative complications, which included ileus (3), deep vein thrombosis (2), wound infection (2), and partial dehiscence of rectal stump (1). Mean length of postoperative hospital stay was 8.8 days.

CONCLUSIONS

These initial data suggest that cyclosporin treatment may not influence the safety of urgent surgical treatment in severe ulcerative colitis.

Anal fissure in Crohn's disease: a plea for aggressive management

PURPOSE

This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease.

METHODS

This is a retrospective review of patients with Crohn's disease and anal fissure.

RESULTS

Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent; P = 0.05) or after abnormal surgery (29 percent; P = 0.03).

CONCLUSION

This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.

A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction

BACKGROUND

Many cases of acute adhesive small-bowel obstruction (SBO) can be successfully treated with intestinal tube decompression. There is considerable controversy, however, regarding whether a short nasogastric tube (NGT) or a long nasointestinal tube (LT) is the best method of intestinal tube decompression.

PATIENTS AND METHODS

A prospective, randomized trial was conducted to compare NGT and LT decompression with respect to the success of nonoperative treatment and morbidity of surgical intervention in 55 patients with acute adhesive SBO.

RESULTS

Twenty-eight patients were managed with NGT and 27 with LT. There were 44 cases of partial SBO (23 NGT, 21 LT) and 11 cases of complete SBO (5 NGT, 6 LT). Twenty-one patients ultimately required operation, including 13 managed with NGT (46%) and 8 with LT (30%) (P = 0.16). The mean period between admission and operation was 60 hours in the NGT group versus 65 hours in the LT group. At operation, 3 patients in the NGT group had ischemic bowel that required resection. Postoperative complications occurred in 23% of patients treated with NGT versus 38% of patients treated with LT (P = 0.89). Postoperative ileus averaged 6.1 days for NGT patients versus 4.6 days for LT patients (P = 0.44). There were no deaths.

CONCLUSIONS

Patients with adhesive SBO can safely be given a trial of tube decompression upon hospital admission. There was no advantage of one type of tube over the other in patients with adhesive SBO.

Adjuvant interferon for anal condyloma. A prospective, randomized trial

PURPOSE

The aim of this study was to determine whether interferon combined with surgical excision and fulguration could reduce the unacceptably high rate of recurrence of anal condyloma seen after surgical extirpation.

METHODS

Forty-three patients with anal condyloma were prospectively randomized into two groups. Group I (n = 25) patients underwent surgical excision and fulguration immediately followed by an injection of 500,000 IU (0.1 ml) of interferon alfa-n3 into each quadrant of the anal canal. Group II (n = 18) patients underwent surgical excision and fulguration but then received four injections (0.1 ml) of saline into each quadrant of the anal canal.

RESULTS

After a mean follow-up of 3.8 months, 10 of 43 (23 percent) patients developed recurrent anal condyloma. Only 3 of 25 (12 percent) interferon-treated patients had recurrences vs. 7 recurrences in 18 (39 percent) saline-treated patients (P = 0.046). Interferon was particularly effective in reducing recurrences in patients whose condylomata were present for more than six months (P = 0.04) and those condylomata that contained human papillomavirus DNA subtype 6/11 (P = 0.05).

CONCLUSION

Adjuvant interferon treatment can reduce the high recurrence rate of anal condyloma seen after surgical extirpation.

Anastomotic-vaginal fistula after colorectal surgery

The most feared complication of anterior and low anterior resection is anastomotic dehiscence. Although most leakages remain clinically silent, some may lead to formation of a colovaginal fistula. At the Lahey Clinic Medical Center, the records of nine patients with colovaginal fistula as a complication of colorectal surgery were reviewed to determine clinical characteristics and optimal management. The mean age was 63.7 years (range, 47-72 years). The initial indications for surgery were carcinoma of the rectum (n = 4), diverticular disease (n = 3), and closure of the colostomy after Hartmann's procedure (n = 2). Hysterectomy had been performed earlier in seven patients (78 percent). The end-to-end anastomosis (EEA) stapling device was used in five patients, and four patients had a handsewn anastomosis. The fistula developed within 23 days after surgery and usually originated within 8 cm of the anal verge. Two patients underwent immediate diverting transverse colostomy. None of the seven patients who were initially managed medically had spontaneous closure of the fistula. High fistulas were successfully treated by colorectal resection in two patients, whereas low fistulas healed after transanal repair without colostomy in two patients. These results suggest that previous hysterectomy predisposes to development of a colovaginal fistula after colorectal surgery. Not all patients require fecal diversion. Colorectal resection for high fistulas and transanal repair for low fistulas appear to be viable options for treatment.

Esophageal tuberculosis: a rare presentation with hematemesis

Esophageal tuberculosis is rare, with only 26 cases previously reported in the literature. Patients usually present with progressive dysphagia or odynophagia. We report a patient with hematemesis that was later attributed to the erosion of tuberculous subcarinal lymph nodes into the esophagus. This presentation has been described in only two other patients, both of whom died of exsanguinating hemorrhage. The successful outcome in the present case rested on the availability of rapid diagnostic modalities and timely surgical intervention.

The freckle sign--an endoscopic feature of the cecum

Mucosal spots, or "freckles," surrounding the appendiceal orifice are an endoscopic feature of the cecum. These are clusters of 1 to 2 mm round or oval slightly raised spots, each with a pale center and an erythematous border. They correlate microscopically with subepithelial and submucosal lymphoid follicles. The freckling pattern, identified in about one third of colonoscopies, was seen best with the videoendoscope and was identified more commonly in patients with systemic illness. Recognition of mucosal freckling around the appendiceal orifice helps identify the cecum and may be useful in the evaluation of cecal and appendiceal pathology.

Gaucher disease: fate of the splenic remnant after partial splenectomy--a case of rapid enlargement

In Gaucher disease, partial splenectomy has been suggested for alleviating the complications of splenomegaly as well as for avoiding the immunologic compromise and potential acceleration of bony and hepatic involvement that may follow total splenic resection. However, the fate of the splenic remnant has been reported rarely. A subtotal splenectomy (85%) was performed in a 19-month-old girl with rapidly progressing Gaucher disease and massive splenomegaly (12% of body weight). Within 3 months, the splenic remnant had increased four-fold in size. Previous reports indicated only three Gaucher patients had significant enlargement of the splenic remnant after partial splenectomy. These findings indicate that splenomegaly may recur rapidly in Gaucher disease following partial splenectomy.

Tetanus after gastrointestinal surgery

Tetanus, which occurs usually as a complication of minor trauma, has also been reported following elective and emergency surgical procedures, particularly those involving the gastrointestinal tract. Early diagnosis of tetanus in the postoperative period is difficult, requiring a high index of suspicion. The possibility of tetanus should be considered in any nonimmunized postoperative patient who develops crampy abdominal pain, fever, and abdominal wall rigidity. Adequate tetanus immunoprophylaxis is essential for all patients undergoing gastrointestinal surgery.