Collaborative Learning Teams to Longitudinally Teach and Assess Teamwork Behaviors and Attitudes

Objective. To create and assess the effectiveness of a model of continuous development of teamwork skills (CDTS), which used a longitudinal peer feedback process across multiple courses that incorporated collaborative team learning. Methods. Pharmacy students participated in collaborative learning teams across the first three years of the doctor of pharmacy (PharmD) curriculum, with team membership changing annually. Self, peer, and team evaluations were completed using the Comprehensive Assessment of Team Member Effectiveness (CATME) Smarter Teamwork system at four time points each year (three formative assessments and one summative assessment). Faculty members used peer and team evaluations to identify when additional coaching on teamwork behaviors, attitudes, and norms was needed. Results. Self, peer, and team evaluations of 261 unique learning teams were conducted between fall 2015 and spring 2018. The majority of students and teams performed highly on teamwork behaviors and attitudes. Individual students and teams were identified for additional development on teamwork behaviors and attitudes as follows: for the 2015-2016 academic year, 5 (2%) individual students and 8 (20%) teams; for the 2016-2017 academic year, 15 (3%) individual students and 19 (22%) teams; and for the 2017-2018 academic year: 15 (2%) individual students and 24 (18%) teams. Conclusion. The CDTS model, which incorporates formative and summative assessments, identified individual students and teams that met the teamwork standards established by the college as well as those students and teams that needed additional coaching to achieve the teamwork learning outcome.

Impact of Team Formation Method on Student Team Performance Across Multiple Courses Incorporating Team-based Learning

Objective. To assess the impact of forming student learning teams based on problem solving styles on team performance and student perceptions of team quality. Methods. This was a prospective observational study involving students in the first year of a Doctor of Pharmacy degree program. Collaborative learning teams (balanced, implementer, optimizer, and random assignment) were created based on students' results on the Basadur Creative Problem Solving Profile Inventory. The teams remained in place across all courses for the first academic year, and those courses that incorporated team-based learning (TBL) were included in the study. Team performance was assessed by administering team readiness assurance tests. The quality of team interactions was assessed using the team satisfaction domain in the Comprehensive Assessment of Team Member Effectiveness (CATME) Smarter Teamwork system and the Team Performance Scale. Results. Each of the 237 first-year pharmacy students enrolled was assigned to one of 41 teams. All teams participated in the study. A significant difference in team performance was observed in the Principles of Patient Centered Care course but not in any of the other courses. No significant differences were found in quality of team interactions. Conclusion. Neither team performance, nor team satisfaction, nor quality of team interactions was impacted by the method of team formation that was used. Given the existing evidence and the results of this study, team formation process, regardless of method used, may have negligible influence on the performance of collaborative learning teams in courses taught using TBL.

An Initial Validation Study of the Self-Rating Scale of Self-Directed Learning for Pharmacy Education

Objective. The purpose of this study was to explore and validate the factor structure of the original SRSSDL scale with pharmacy students enrolled in a four-year Doctor of Pharmacy program at a southeastern university, and to assess the differences in the self-directed learning behaviors across different class years of students. Methods. Factor analysis was used to identify the factor structure of a self-rating scale of self-directed learning (SRSSDL) among pharmacy students (n=872) and to examine students' self-directed learning (SDL) behaviors by year in the pharmacy education curriculum. Results. Five factors - intrinsic motivation, awareness, collaboration, reflection and application - showed acceptable levels of reliability. P4 students scored significantly higher than P2 students on the total scale. P4 students scored significantly higher on awareness than P1 and P2 students, while P2 students had a significantly higher collaboration score compared to P1 students. Conclusion. The revised 55-item SRSSDL is a valid and homogenous scale of pharmacy students' self-directed learning within one pharmacy program. However, due to differences in factor structure compared to earlier studies, further research is needed before this survey tool can be broadly implemented in pharmacy education.

Perceptions of pharmacy faculty need for development in educational research

INTRODUCTION

Pharmacy educators have identified that pharmacy faculty need a better understanding of educational research to facilitate improvement of teaching, curricula, and related outcomes. However, the specific faculty development needs have not been assessed. The purpose of this study was to investigate self-reported confidence among clinical doctor of pharmacy faculty in skills essential for conducting educational research.

METHODS

Faculty members with primary responsibilities in teaching at the University of Florida College of Pharmacy were invited to the take the Adapted Self-Efficacy in Research Measure (ASERM). Descriptive analysis and independent samples t-tests were used to compare the self-efficacy items by faculty rank, gender, and years of experience.

RESULTS

Twenty-two of the 37 faculty members answered the 30-item survey that identified their self-efficacy in items and categories of skills, including writing skills, statistical skills, research design, research management and dissemination in education research. Senior faculty had significantly higher confidence than junior faculty on seven items. Participants who worked more than ten years had statistically higher confidence in preparing and submitting grant proposals to obtain funding for educational research. Skills where both junior and senior faculty had low confidence were related to using non-traditional methods such as qualitative methods and identifying funding resources for educational research.

DISCUSSION AND CONCLUSIONS

Findings from the ASERM provided insights among pharmacy educators regarding self-efficacy related to skills needed for educational research, options for faculty development opportunities and actions for improving educational research knowledge and skills among them.

Performance-Based Assessment: Using Pre-Established Criteria and Continuous Feedback to Enhance a Student’s Ability to Perform Practice Tasks

Performance-based assessment is a process in which pre-established performance criteria and continuous feedback are used by both the student and instructor to improve learning with an endpoint of students demonstrating their achievement of learning by performing realistic practice tasks. This manuscript describes the issues limiting widespread use of performance-based assessment, based on findings from the pharmacy, medical, and general education literature, and then proposes a model for how to successfully implement it. Performance-based assessment methods such as direct observation, the Mini-Clinical Evaluation Exercise, simulations involving standardized patients and computers, projects, presentations, learning portfolios, and the Triple Jump Exam are discussed. Successful implementation of performance-based assessment involves: 1) inculcating a culture for assessment, 2) establishing pre-specified performance criteria, 3) implementing use of the pre-established performance criteria and formative assessment methods to provide continuous feedback during the learning period, 4) using summative performance-based assessment methods, and 5) providing mechanisms for student remediation. Successful inclusion of performance-based assessment in Doctor of Pharmacy curricula should enable instructors to better prepare graduates that can provide pharmaceutical care in a quality manner.

Center for the Advancement of Pharmacy Education 2013 educational outcomes

An initiative of the Center for the Advancement of Pharmacy Education (formerly the Center for the Advancement of Pharmaceutical Education) (CAPE), the CAPE Educational Outcomes are intended to be the target toward which the evolving pharmacy curriculum should be aimed. Their development was guided by an advisory panel composed of educators and practitioners nominated for participation by practitioner organizations. CAPE 2013 represents the fourth iteration of the Educational Outcomes, preceded by CAPE 1992, CAPE 1998 and CAPE 2004 respectively. The CAPE 2013 Educational Outcomes were released at the AACP July 2013 Annual meeting and have been revised to include 4 broad domains, 15 subdomains, and example learning objectives.

Calculation of the effect of pressurizing gases on the resonant modes of single-crystal parallelepiped

Resonant ultrasound spectroscopy provides for an experimental determination of the elastic moduli of a solid sample. The moduli are extracted by matching a theoretically computed resonant spectrum to the experimental vibrational spectrum. To determine the pressure dependence of the moduli, the vibrational spectrum can be taken with the sample in a pressurizing gas. Then the extraction of the intrinsic, pressure dependent moduli requires a theoretical treatment which permits removal of the perturbation of the spectrum due to the surface loading by the pressure and shear waves in the gas. In order to illustrate a treatment which accomplishes this removal, the theoretically computed frequency shifts and the quality factors are reported for two single-crystal parallelepiped pressurized by noble gases.

Roles of innovation in education delivery

This paper reviews trends in higher education, characterizing both the current learning environments in pharmacy education as well as a vision for future learning environments, and outlines a strategy for successful implementation of innovations in educational delivery. The following 3 areas of focus are addressed: (1) rejecting the use of the majority of classroom time for the simple transmission of factual information to students; (2) challenging students to think critically, communicate lucidly, and synthesize broadly in order to solve problems; and (3) adopting a philosophy of "evidence-based education" as a core construct of instructional innovation and reform.

Rayleigh-ritz calculation of the resonant modes of a solid parallelepiped in a pressurizing fluid

Resonant ultrasound spectroscopy relies on comparisons of experimentally determined vibrational spectra to theoretically computed spectra for the extraction of the elastic moduli of the solid samples. To determine the pressure dependence of these moduli, resonant spectra are taken for samples pressurized by a surrounding gas and knowledge of the contribution of the surface loading of the sample by the gas is needed in order to extract the intrinsic pressure dependence of the moduli. To facilitate the required comparisons, a Rayleigh-Ritz variational calculation of the vibrational spectrum is formulated which includes the loading of the solid by the pressurizing fluid. This formalism is used to compute the effect of gas loading on the vibrational spectrum of an isotropic, solid parallelepiped.

Colonoscopy in the patient requiring anticoagulation

PURPOSE

The aim of this study was to assess perioperative warfarin management and complications in patients requiring colonoscopy.

METHODS

We retrospectively reviewed 109 cases of colonoscopies performed on 94 patients requiring anticoagulation with warfarin. Patients stopped their warfarin three days before colonoscopy. Coagulation profiles obtained just before the colonoscopy showed a median prothrombin time of 13.4 seconds with a range of 11.1 to 29.1 (normal range, 10.9-13) and a median international normalized ratio of 1.2 with a range of 0.9 to 2.6. Patients restarted warfarin the day after the examination.

RESULTS

During the 109 colonoscopies, 47 percent of the patients underwent either hot biopsy or snare polypectomy. One examination that included several biopsies was associated with a hemorrhagic complication (0.92 percent) requiring hospitalization and transfusion. Subset analysis of the therapeutic (biopsy and snare polypectomy) group indicated a slightly higher complication rate (1.96 percent) with a median international normalized ratio of 1.3 (range, 1-2.3) and a median prothrombin time of 13.7 (range, 11.6-25.9).

CONCLUSION

Patients taking warfarin for anticoagulation may safely undergo colonoscopy. The risk of hemorrhagic complications increases slightly with hot biopsy or snare procedures. Further studies are needed to refine guidelines for colonoscopy in the patient requiring anticoagulation.

Colonoscopic perforations

PURPOSE

This study was designed to assess the medical and surgical treatment of colonoscopic perforations.

METHODS

A retrospective review of colonoscopic perforations from 1970 to 1999 was performed.

RESULTS

In 30 years, 34,620 colonoscopies resulted in 31 (0.09 percent) perforations. Eighteen (58 percent) resulted from therapeutic colonoscopies, whereas 13 (42 percent) occurred after diagnostic colonoscopies. Sixteen perforations (52 percent) were identified during the procedure, 13 (42 percent) within 24 hours, and two (6 percent) within 48 hours. Twenty patients (65 percent) underwent surgical therapy, and 11 (35 percent) were treated medically with intestinal rest and intravenous antibiotics. In the medically treated group, one patient required rehospitalization for percutaneous drainage of an intra-abdominal abscess, and one patient died after requesting no further treatment because of an underlying terminal medical condition. Three patients failed medical treatment and required surgical intervention. One underwent repair with proximal diversion, whereas the remaining two received a colorrhaphy without resection or diversion. In the surgical treatment group, nine patients received colorrhaphy without diversion, seven underwent resection with primary anastomosis, and four had resection with diversion.

CONCLUSION

Selected patients with colonoscopic perforation may be safely treated nonoperatively. Surgical treatment is reserved for patients with a large perforation or diffuse peritonitis.

Restorative proctocolectomy: Ochsner Clinic experience

BACKGROUND

Restorative proctocolectomy, a standard operation for ulcerative colitis and familial adenomatous polyposis has significant complications, even in experienced hands.

METHODS

We studied surgical outcome by retrospectively reviewing cases of restorative proctocolectomy done at Ochsner Foundation Hospital from 1982 to 1995. Demographic and clinical data from two periods (1982 to 1989 and 1989 to 1995) were compared to determine factors associated with improved outcome.

RESULTS

We performed 145 ileal pouch-anal procedures. In 56 patients, 104 complications occurred. The more recent group had a greater incidence of inflammatory bowel disease, steroid use, and staged operations; reduced operative times and hospital stays; more general but fewer pouch-related complications. Pouch failures were similar for both groups.

CONCLUSIONS

Perioperative outcome appeared to be associated with technical experience, improved perioperative care, exclusion of patients with Crohn's disease,judicious surgical reoperation for pouch complications, and use of a 3-stage procedure in malnourished patients or those with acute or toxic colitis.

Effect of previous surgery on abdominal opening time

PURPOSE

The purpose of this study was to document prospectively the time required to gain access to the abdomen to perform a planned procedure in patients with and without previous surgery.

METHODS

Patients were obtained from the consecutive cases of 11 surgeons at three colorectal surgery centers. Opening time (skin incision to retractor placement) was measured and recorded in the operating room by the circulating nurse or by an independent researcher. Demographic data including the number and type of previous operations and the presence and severity of adhesions were recorded by the staff surgeon. A comparison of opening times between patients with and without previous abdominal operations was conducted.

RESULTS

One hundred ninety-eight patients had abdominal operations. Fifty-five percent had previous abdominal procedures. Patients with prior surgery required a mean of 21 minutes to open their abdomens, whereas patients without prior surgery required a mean of 6 minutes (P < 0.01). The median times were 17 and 6 minutes, respectively. Eighty-three percent of patients with prior surgery had adhesions, whereas only 7 percent of patients had adhesions on their initial operation. Patients with prior surgery also had higher grade adhesions (P < 0.001). Irrespective of previous surgery, comparing patients with adhesions with those without, patients with adhesions required a mean of 22 minutes to open, whereas the lack of adhesions resulted in a mean opening time of 6 minutes.

CONCLUSIONS

Previous surgery and the presence of adhesions add significant time to opening the abdomen.

Outcomes and experiential education

Outcomes-based assessment in education involves continuous use of assessment measures to provide feedback about the efficacy of the curricular structure, content, and teaching methods. This process is initiated by establishing educational outcome statements for the Doctor of Pharmacy curriculum, selecting assessment methods that most appropriately measure the educational outcomes, and establishing a learning environment that is congruent with both the outcomes and assessment methods. To ensure a successful continuous outcomes-based assessment process, a systematic assessment plan should be prepared that focuses the process by identifying only the most essential hypotheses, uses a practical yet appropriate methodology, ensures efficient data collection, includes data analyses that link the educational outcomes to the learning environment, and promotes timely development and implementation of an action plan. An overview of outcomes-based education and the use of outcomes-based practice experiences in pharmacy education is presented.

Significance of a normal surveillance colonoscopy in patients with a history of adenomatous polyps

PURPOSE

The aim of this study was to determine the appropriate surveillance for patients with a history of adenomatous polyps whose last colonoscopic examination was normal.

METHODS

This was a retrospective review of a database of 7,677 colonoscopies (1990 to 1996). In patients under colonoscopic surveillance, we reviewed cases of patients who had received three colonoscopies (an index (initial) colonoscopy positive for adenomas and 2 follow-up colonoscopies (interim and final)). The risk of adenomas and cancers at final follow-up colonoscopy was compared between patients having a normal interim colonoscopy and those with a positive interim colonoscopy. The risk at final colonoscopy was also stratified by time interval and the size and number of adenomas at the initial index colonoscopy.

RESULTS

Two hundred four patients undergoing surveillance for adenomas met inclusion criteria. At index colonoscopy the median polyp size was 1 cm and median frequency was three polyps. At all follow-up colonoscopies, we detected 493 adenomas and one cancer (median follow-up, 55 months). At 36 months patients with a normal interim colonoscopy (n = 91) had significantly fewer polyps than patients with a positive interim colonoscopy (n = 113; 15 vs. 40 percent; P = 0.0001). By 40 months, adenomas were detected in more than 40 percent of patients in both groups. The risk after a normal interim colonoscopy was not affected by time interval or number or size of polyps. Adenomas found subsequent to a normal interim colonoscopy were dispersed throughout the colon in 28 patients and isolated to the rectosigmoid in 6 patients.

CONCLUSIONS

In patients with a history of adenomas, a normal follow-up colonoscopy is associated with a statistically but not clinically significant reduction in the risk of subsequent colonic neoplasms. These patients require follow-up surveillance colonoscopy at a four-year to five-year interval.

The natural history of isolated rectosigmoid adenomatous polyps: is flexible sigmoidoscopy a safe alternative for surveillance?

PURPOSE

Colonoscopic surveillance is recommended for patients with adenomatous polyps. Significant cost savings would result from identification of subgroups of patients in whom less costly surveillance would suffice. This study was performed to determine the natural history of patients undergoing removal of isolated rectosigmoid adenomas and to establish whether flexible sigmoidoscopy might be adequate for follow-up.

METHODS

A retrospective review of a database of 7,677 colonoscopies, from 1990 to 1996, identified patients who had a minimal follow-up of two years after removal of adenomatous polyps isolated to the rectosigmoid. Polyps detected on surveillance colonoscopy were categorized as distal (< or =60 cm from anal verge), proximal (>60 cm from anal verge), and diffuse (proximal plus distal). The risk of polyp formation was determined by actuarial analysis using the Kaplan-Meier method.

RESULTS

Sixty-two patients undergoing surveillance for adenomas met inclusion criteria. At the index colonoscopy, 124 isolated rectosigmoid polyps were identified. The median polyp size was 1 cm and median frequency was one polyp. The median follow-up time for the entire cohort (N = 62) was 53 months. At follow-up surveillance colonoscopy, 105 additional adenomas were discovered and removed in 40 patients. No malignant polyps were detected. The pattern of polyps detected were proximal (n = 19), rectosigmoid (n = 16), and diffuse (n = 5).

CONCLUSIONS

The majority (65 percent) of patients with isolated rectosigmoid polyps have additional polyps on long-term surveillance, and 60 percent of patients will have these polyps located proximal to the reach of a sigmoidoscope. Therefore, flexible sigmoidoscopy is not a safe alternative for surveillance of patients with isolated rectosigmoid polyps.

Discontinuous appendiceal involvement in ulcerative colitis: pathology and clinical correlation

Continuous mucosal involvement from the rectum proximally is one of the hallmarks of ulcerative colitis. However, recent pathologic series report appendiceal ulcerative colitis in the presence of a histologically normal cecum, representing a "skip" lesion. The clinical significance of this finding has not been established. Eighty patients, 54 males and 26 females, average age 37.9 years (range 14 to 82 years) who underwent proctocolectomy for ulcerative colitis from January 1990 to September 1995 were examined to determine the rate of discontinuous appendiceal involvement. Excluded were 12 patients with prior appendectomy and 11 with fibrotic obliteration of the appendiceal lumen. Of the remaining 57 patients, seven (12.3%) had clear appendiceal involvement in the presence of a histologically normal cecum. These seven patients clinically were indistinguishable from the 50 patients without skip involvement of the appendix in terms of age at surgery, pretreatment medications, type of surgery, interval from diagnosis to definitive procedure, complications, functional results, and clinical course. Discontinuous appendiceal involvement was found in 12.3% of patients undergoing proctocolectomy for ulcerative colitis, and clinically these patients behave as those without this feature.

Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery

PURPOSE

The study contained herein was undertaken to establish the incidence of small-bowel obstruction, adhesiolysis for obstruction, and additional abdominal surgery after open colorectal and general surgery.

METHODS

A retrospective cohort study was performed using patient-specific Health Care Financing Administration data to evaluate a random 5 percent sample of all Medicare patients who underwent surgery in 1993. Of these, 18,912 patients had an index abdominal procedure. Two-year follow-up data documented outcomes of hospitalizations with obstruction, adhesiolysis for obstruction, and/or additional open colorectal or general surgery.

RESULTS

Within two years of incision, excision, and anastomosis of intestine (International Classification of Dis eases (ICD)-9 code 45), 14.3 percent of patients had obstructions, 2.6 percent required adhesiolysis for obstructions, and 12.9 percent underwent additional open colorectal or general surgery. After other operations of intestine (ICD code 46), 17 percent of patients had obstructions, 3.1 percent required adhesiolysis for obstructions, and 20.2 percent underwent additional open colorectal or general surgery. After operations of rectum, rectosigmoid, and perirectal tissue (ICD code 48), 15.3 percent of patients had obstructions, 5.1 percent required adhesiolysis for obstructions, and 16.4 percent underwent additional open colorectal or general surgery. After other operations on the abdominal region (ICD code 54), 12.4 percent of patients had obstructions, 2.3 percent required adhesiolysis for obstructions, and 8.8 percent underwent additional open colorectal or general surgery.

CONCLUSIONS

In this retrospective study of Medicare patients, we learned that bowel obstruction, adhesiolysis for obstructions, and additional abdominal surgery occurred more often after abdominal surgery than was previously published.

Quantitation of dolastatin-10 using HPLC/electrospray ionization mass spectrometry: application in a phase I clinical trial

A highly sensitive and specific assay for the quantitation of the anticancer agent dolastatin-10 (DOL-10) in human plasma is described. The method was based on the use of electrospray ionization-high-performance liquid chromatography/mass spectrometry (ESP-LC/MS). The analytical procedure involved extraction of plasma samples containing DOL-10 and the internal standard (DOL-15) with n-butyl chloride, which was then evaporated under nitrogen. The residue was dissolved in 50 microl mobile phase and 10 microl was subjected to ESP-LC/MS analysis using a C18 microbore column. A linear gradient using water/acetonitrile was used to keep the retention times of the analytes of interest under 5 min. The method exhibited a linear range from 0.005 to 50 ng/ml with a lower limit of quantitation (LLQ) at 0.005 ng/ml. Absolute recoveries of extracted samples in the 85-90% range were obtained. The method's accuracy (< or =5% relative error) and precision (< or =10% CV) were well within industry standards. The analytical procedure was applied to extract DOL-10 metabolites from samples obtained following incubation of the drug with an activated S9 rat liver preparation. Two metabolic products were detected and were tentatively identified as a N-demethyl-DOL-10 and hydroxy-DOL-10. Structural assignments were made based on the fragmentation patterns obtained using the electrospray source to produce collision-induced dissociation (CID). The method was also applied to the measurement of DOL-10 in the plasma of patients treated with this drug. Preliminary investigation of the pharmacokinetics suggested that drug distribution and elimination may be best described by a three-compartment model with t1/2alpha = 0.087 h, t1/2beta = 0.69 h and t1/2gamma = 8.0 h. Plasma clearance was 3.7 l/h per m2.

Long-term survival after treatment of malignant colonic polyps

PURPOSE

This study was designed to evaluate the long-term outcome and survival of patients treated for malignant colonic polyps.

METHODS

A retrospective review of 15,975 cases of colonoscopies with 8,685 endoscopic polypectomies performed between 1972 and 1990 was undertaken. In 65 patients, the polypectomy specimens contained invasive carcinoma. Six patients were excluded (follow-up, <6 months). Polyp data, operative findings, and follow-up on the remaining 59 patients were recorded.

RESULTS

Malignant polyps were found in 35 males and 24 females who had an average age of 64 (range, 39-81) years. Follow-up ranged from 12 to 202 (mean, 90) months. Tumor differentiation was poor in one and well or moderately differentiated in 58 patients. Positive or indeterminate margins were found in 13 patients. Thirty-seven (63 percent) patients were managed with polypectomy and surveillance. Four of these (with rectal tumors) also had an additional local excision for questionable margins. One recurrence was noted in a patient who refused surgery, which was recommended because of indeterminate margins. Twenty-two patients (37 percent) underwent colectomy. Indications included Haggitt Level 3 or 4 invasion (19), inadequate margins (7), patient preference (1), and poor differentiation (1). Residual disease was found in colectomy specimens of three patients (14 percent). There were no cancer-related deaths in either treatment group. Life table analysis demonstrated a five-year survival of 82 percent for the colectomy group and 95 percent for the polypectomy group (P = 0.15).

CONCLUSION

Treatment of patients with malignant polyps must be individualized based on evolving criteria. Patients in whom polypectomy margins are inadequate should undergo colectomy. With appropriate selection criteria, patients selected for colectomy had a five-year survival rate similar to the rate of those treated by polypectomy alone.

Treatment of colorectal and ileoanal anastomotic sinuses

PURPOSE

This study is designed to describe a technique and report results for treating low anastomotic sinuses.

METHODS

Restorative proctocolectomy and complicated low anterior resections were protected with diverting loop ileostomy. Contrast enemas identified anastomotic problems before ileostomy closure. Pouch-anal or colorectal anastomotic sinuses that failed to resolve with observation were treated before intestinal continuity was restored. With the patient receiving regional or general anesthesia, a rigid proctoscope or anoscope was used to identify the sinus opening. The common wall between the sinus and the bowel lumen was divided under direct vision with laparoscopic cautery scissors, and the sinus cavity was debrided with a suction cautery wand placed through the scope.

RESULTS

Six patients with anastomotic sinuses have received outpatient treatment in the described manner during the past two years. Four patients had restorative proctocolectomies for ulcerative colitis, and two had low anastomosis for rectal cancer. Three patients presented with pelvic sepsis before the contrast study; the remainder were asymptomatic. Division of anastomotic sinus was performed one to eight months after diagnosis of the sinus. Following division, anastomotic cavities resolved in five patients by 1 month and in one patient by 12 months. In these six patients, there was one dilatable anastomotic stricture but no other anastomotic complications at follow-up 5 to 16 (mean, 9.2) months after sinus division.

CONCLUSION

When used in conjunction with fecal diversion, sinus unroofing by division of the common wall between the sinus and bowel lumen treats low pelvic sinuses.

Outpatient bowel preparation for elective colon resection

To determine the safety and cost-effectiveness of outpatient preoperative bowel preparation with polyethylene glycol-electrolyte lavage solution, we retrospectively analyzed 726 cases of colectomy done by colon and rectal surgeons between July 1987 and July 1991. Included were 319 patients who had elective segmental or total abdominal colectomy with primary anastomosis. Patients who required protective proximal stoma were excluded. Patients requiring emergency surgery, colostomy closure, and restorative proctocolectomy were excluded. Patients were separated into two groups equally matched by age, sex, procedure done, and comorbidity: 145 had bowel preparation as outpatients and 174 as inpatients. Both groups had similar numbers of days hospitalized, days receiving nothing by mouth, and days requiring nasogastric intubation or gastrostomy tube, as well as similar postoperative complications. There was one wound infection, one anastomotic leak, and one death in each group. Cost of outpatient preparation was approximately $40. Cost of inpatient preparation, including a semiprivate room, was approximately $400. Outpatient preparation with polyethylene glycol-electrolyte lavage solution and oral antibiotics before elective colon resection can be done with equivalent safety and at a substantial cost savings.

Predictive value of technetium Tc 99m-labeled red blood cell scintigraphy for positive angiogram in massive lower gastrointestinal hemorrhage

PURPOSE

This study was performed to evaluate whether the time interval from injection of technetium Tc 99m (99mTc)-labeled red blood cells to the time of a radionuclide "blush" (positive scan) can be used to improve the efficacy in predicting a positive angiogram.

METHOD

A retrospective review revealed 160 patients who received 99mTc-labeled red blood cell scintigraphy for evaluation of massive lower gastrointestinal hemorrhage between 1989 and 1994. Patients were included who demonstrated signs of shock on admission, had an initial decrease in hematocrit of > or = 6 percent, or required a minimum transfusion of two units of packed red blood cells. Scanning duration was 90 minutes, with imaging every 2 minutes. Time interval from injection to a positive scan was analyzed to determine predictability of a positive angiography.

RESULTS

Of 160 patients, 86 demonstrated positive scans, of whom 47 underwent angiography. These 47 patients were divided into two groups according to scan results. Group 1 (n = 33) had immediate appearance of blush; Group 2 (n = 14) had blush after two minutes. In Group 1, 20 of 33 patients had a positive angiogram, yielding a positive predictive value of 60 percent (P = 0.033). Of the 14 patients with negative angiograms (13 from Group 1, and 1 with a negative scan), 6 had radiographic occlusion of the inferior mesenteric artery and 1 had spasm of the right colic artery, with scans that blushed in the respective distributions. Excluding these seven patients yielded a positive predictive value of 75 percent (P = 0.0072) for angiography. In patients with a delayed blush (Group 2), 13 of 14 had negative angiograms, yielding a negative predictive value of 93 percent (92 percent excluding those with nonvisualization of the inferior mesenteric artery). Twenty of 21 (95 percent) positive angiograms occurred in Group 1 patients. Of the 27 patients with negative angiograms, 13 were Group 2 patients.

CONCLUSION

Patients with immediate blush on 99mTc-labeled red blood cell scintigraphy required urgent angiography. Patients with delayed blush have low angiographic yields. These data suggest that patients with delayed blush or negative scans may be observed and evaluated with colonoscopy.

Adhesions: pathogenesis and prevention-panel discussion and summary

This article summarizes the discussions of the faculty and chairpersons on four major topics on postsurgical adhesions examined at the symposium, "Adhesions: Pathogenesis and Prevention". These topics are: 1) clinical significance; 2) pathogenesis; 3) research status and directions; and 4) recommendations for reduction or prevention. Abdominal postsurgical adhesions develop following trauma to the mesothelium, which is damaged often by surgical handling and instrument contact, foreign materials such as sutures and glove dusting powder, desiccation, and overheating. Postoperative adhesions occur after most surgical procedures and can result in serious complications, including intestinal obstruction, infertility, and pain. A long-term and unpredictable problem, postoperative adhesions impact the surgical workload and hospital resources, resulting in considerable health care expenditures. Although understanding of the pathogenesis of adhesions has improved recently, the molecular mechanisms involved continue to be delineated. Adhesions result from the normal peritoneal wound healing response and develop in the first five to seven days after injury. Adhesion formation and adhesion-free re-epithelialization are alternative pathways, both of which begin with coagulation which initiates a cascade of events resulting in the buildup of fibrin gel matrix. If not removed, the fibrin gel matrix serves as the progenitor to adhesions by forming a band or bridge when two peritoneal surfaces coated with it are apposed. The band or bridge becomes the basis for the organization of an adhesion. Protective fibrinolytic enzyme systems of the peritoneum, such as the plasmin system, can remove the fibrin gel matrix. However, surgery dramatically diminishes fibrinolytic activity. The pivotal events determining whether the pathway taken is adhesion formation or re-epithelialization are therefore the apposition of two damaged surfaces and the extent of fibrinolysis. Research in postsurgical adhesion formation and prevention abounds in a variety of avenues of investigation, including: 1) identification on a molecular level of the components involved in adhesiogenesis and their interactions; 2) clarification of the role of fibrin and fibrinolysis in adhesion formation; 3) standardization of design in preclinical and clinical studies of adhesion formation and prevention; 4) delineation of the relationship between adhesion formation and adhesive complications; and 5) elucidation of efficient, site-specific methods of prophylactic drug delivery. Currently, it seems logical to focus preventive research on development of barriers, fibrinolytic drugs, and selected agents such as phospholipids. The major strategies for adhesion prevention or reduction are adjusting surgical practice and applying adjuvants. Surgeons should adjust their major practices by: 1) becoming aware of the potential adhesive complications of a procedure; 2) minimizing the invasiveness of surgery; and 3) minimizing surgical trauma, ischemia, exposure to intestinal contents, introduction of foreign material into the body, and the use of talc- or starch-containing gloves. Available adjuvants include a newly developed by hyaluronic acid-phosphate-buffered saline solution applied intraoperatively to protect peritoneal surfaces from indirect surgical trauma and three mechanical barriers. One of these, a bioresorbable membrane consisting of hyaluronic acid and carboxymethylcellulose, has demonstrated efficacy and safety in both general and gynecological surgery. The other two barriers, one made of expanded polytetrafluoroethylene and one developed from oxidized regenerated cellulose, are indicated only for use in gynecological surgery.

The role of Seprafilm bioresorbable membrane in adhesion prevention

OBJECTIVE

To evaluate, the safety and efficacy of Seprafilm, a novel bioresorbable membrane of chemically modified hyaluronic acid and carboxymethylcellulose, in preventing and reducing postoperative adhesion formation.

DESIGN

Randomized, controlled, blinded, prospective multicenter study.

SETTING

Major academic surgical centers.

SUBJECTS

183 (treatment, n = 91; control, n = 92) patients with ulcerative colitis or familial polyposis.

INTERVENTIONS

Restorative proctocolectomy and ileal J-pouch anastomosis with diverting ileostomy followed by second-stage laparoscopy for ileostomy closure and direct visual assessment of the peritoneal cavity. Before abdominal closure in treated patients, Seprafilm, averaging 406.9 cm2 per patient, was applied without suturing between the midline incision and underlying tissues and organs.

MAIN OUTCOME MEASURES

Determination of the incidence, extent (mean percentage of midline incision associated with adhesions), severity (grade 1, least severe; grade 2, moderately severe; grade 3, very severe), and distribution of adhesions.

RESULTS

In 175 (treatment, n = 90) evaluable patients, Seprafilm significantly reduced the incidence (49% and 94%, respectively, p < 0.0001), extent (23% and 63%, respectively, p < 0.0001), and severity (15% versus 58% grade 3 severity, respectively, p < 0.0001) of postoperative adhesions. Seprafilm decreased the rate of adhesion formation by nearly 50%. More than half (51%) of Seprafilm recipients were adhesion-free, versus only 6% of untreated patients. Thus treated patients were eight times more likely to be free of adhesions than untreated controls. The incidence of incisional adhesions associated with the omentum, small bowel, left sidewall, bladder, ileostomy, and stomach was significantly reduced in the Seprafilm patients. Effects on vital signs and laboratory parameters were comparable in the two groups and were attributable to the operative procedure, concomitant therapy, or comorbid disease. All reported adverse events were associated with the surgical procedure and/or comorbid disease and did not differ significantly between the two groups (p > 0.05).

CONCLUSION

Seprafilm is safe and significantly reduces the incidence, extent, and severity of postoperative adhesions to the midline incision compared with no treatment, the current standard of surgical care.

Perineal repair of rectal prolapse

Perineal approaches to the repair of rectal prolapse are frequently used in elderly or high-risk patients. These repairs have lower operative mortality and morbidity than intra-abdominal repairs but in general have higher recurrence rates. This study reviews our recent results with perineal prolapse repairs, briefly summarizes the literature, and discusses the available perineal operations. Eight patients (mean age 75 years) underwent surgical prolapse repair over an 18-month period. Treatment was by Altemeier's procedure (perineal rectosigmoidectomy) in 6 patients and Delorme's procedure in 2 patients. There were no operative mortalities, and an anastomotic dehiscence in 1 patient was managed nonoperatively. All patients with preoperative constipation improved and no patient reported worsening of continence. Surgical approaches from the perineum may be used in elderly and poor risk patients to treat rectal prolapse with low mortality and morbidity. These techniques have not adversely affected fecal continence and have improved symptoms of constipation with an acceptable rate of recurrence.

Chronic perioperative steroids and colonic anastomotic healing in rats

OBJECTIVE

To develop a rat model of long-term high-dose perioperative steroids and to evaluate the effects of these steroids on a colonic anastomosis in this model.

DESIGN

Prospective randomized.

METHODS

Twenty-six male Sprague-Dawley rats, weighing 270 to 330 g, were randomized into two groups. The first group (steroid group) (13 rats) received a time-release drug pellet (200 mg cortisone acetate in a 60-day release form) placed in the subcutaneous tissue of the posterior neck for an average daily dose of 3.3 mg. The second group (control group) (13 rats) received a placebo. At 6 weeks, blood cortisol levels were measured, and a colonic anastomosis was performed 2.5 cm distal to the cecum. Steroid group animals also received cortisone acetate (5 mg intramuscularly) immediately before surgery. Colonic bursting strength (mmHg) was measured at the anastomosis site and in the normal distal left colon using a saline infusion system at 8 and 12 days postoperatively.

RESULTS

Blood cortisol levels were significantly higher in the rats in the steroid group than in the rats in the control group. The anastomotic bursting strength was significantly lower in the steroid group at Days 8 and 12. The bursting pressure of the unoperated left colon was not significantly different when the groups were compared. Also, in the steroid group, healing of the pellet insertion wounds in the neck was impaired.

CONCLUSION

The time-release drug pellet is a reliable method of administering long-term steroids. Long-term perioperative steroids impaired colonic anastomotic healing, while normal tissue strength (left colon) was not significantly changed.

Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study

BACKGROUND

Postoperative abdominal adhesions are associated with numerous complications, including small bowel obstruction, difficult and dangerous reoperations, and infertility. A sodium hyaluronate and carboxymethylcellulose bioresorbable membrane (HA membrane) was developed to reduce formation of postoperative adhesions. The objectives of our prospective study were to assess the incidence of adhesions that recurred after a standardized major abdominal operation using direct laparoscopic peritoneal imaging and to determine the safety and effectiveness of HA membrane in preventing postoperative adhesions.

STUDY DESIGN

Eleven centers enrolled 183 patients with ulcerative colitis or familial polyposis who were scheduled for colectomy and ileal pouch-anal anastomosis with diverting-loop ileostomy. Before abdominal closure, patients were randomly assigned to receive or not receive HA membrane placed under the midline incision. At ileostomy closure eight to 12 weeks later, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision.

RESULTS

Data were analyzed for 175 assessable patients. While only five (6 percent) of 90 control patients had no adhesions, 43 (51 percent) of 85 patients receiving HA membrane were free of adhesions (p < 0.00000000001). The mean percent of the incision length involved was 63 percent in the control group, significantly greater than the 23 percent observed in patients who received HA membrane (p < 0.001). Dense adhesions were observed in 52 (58 percent) of the 90 control patients, but in only 13 (15 percent) of the 85 receiving HA membrane (P < 0.0001). Comparison of the incidence of specific adverse events between the groups did not identify a difference (P > 0.05).

CONCLUSIONS

This study represents the first controlled, prospective evaluation of postoperative abdominal adhesion formation and prevention after general abdominal surgery using standardized, direct peritoneal visualization. In this study, HA membrane was safe and significantly reduced the incidence, extent, and severity of postoperative abdominal adhesions.

Perioperative steroid use in colorectal patients. Results of a survey

PURPOSE

A survey was conducted to document current perioperative steroid use in colorectal patients.

METHODS

A mail survey was sent to 1,400 members and fellows of The American Society of Colon and Rectal Surgeons.

RESULTS

Three hundred seven questionnaires (21.9 percent) were returned. Twenty-four respondents had retired or lacked accurate data. The remaining 283 surgeons averaged 43.5 (range, 31-71) years in age and had been in practice an average of 11 (range, 1-39) years. Ninety-seven percent were certified by the American Board of Surgery, 87 percent by the American Board of Colon and Rectal Surgery, and 85 percent by both. Eighty-six percent of respondents manage the perioperative steroids and 85 percent manage the postoperative steroid taper of their patients. In patients receiving preoperative steroids, 84 percent of respondents administer 100 mg of hydrocortisone phosphate intravenously before surgery. The most common postoperative dosage (used by 62 percent) was 100 mg of hydrocortisone phosphate intravenously every eight hours, which was tapered to 50 mg intravenously every 8 to 12 hours. Most patients (49 percent) received 20 mg of prednisone per day when their oral intake was resumed. The most common taper regimen was a 5 mg reduction per week (61 percent of respondents).

CONCLUSION

Despite lack of scientifically established requirements or proven physiologic guidelines, perioperative steroid use by colorectal surgeons appears relatively consistent.

Surgical excision of large rectal villous adenomas

Large villous tumors occur most frequently in the rectosigmoid and have a significant incidence of harboring a malignancy. The presence or absence of malignancy may be determined only by complete excision. Presence of invasive carcinoma on pathologic examination requires surgical intervention appropriate for that diagnosis. Recurrence depends on the technique used for tumor removal. It is highest for fulguration and local excision and lowest for operations that excise all or part of the rectum. Because most recurrences can be managed with local measures and the risk of malignancy in recurrences is relatively low, the procedure with which the tumor can be completely excised with the least morbidity should be used. Local excision with or without mucosal closure should be used as first-line surgical therapy whenever possible. It should be possible to manage most tumors in the mid and low rectum with this technique. For larger tumors and those tumors more proximal, it may be necessary to use snare cautery in combination with local excision or fulguration. Alternately, for some proximal rectal lesions the two-scope technique mentioned earlier may allow local excision. For circumferential or near circumferential tumors in the low to mid rectum, circumferential mucosectomy should be used. It has been used successfully for tumors involving the entire rectum down to the dentate line. Although this technique has a low recurrence rate, the rate of incontinence associated with it precludes its use in smaller tumors that are amenable to local excision. Transanal endoscopic microsurgery described by Beuss et al can produce good results. The authors have no experience with this technique. However, because of its expense, the need for specialized training, and the infrequency with which other transanal techniques are insufficient, we fail to see a significant role for its use. If use of this technique becomes more widespread, additional data regarding its value will become available. Posterior approaches offer no advantage for removal of tumors that can be excised by transanal techniques. Most tumors that require partial or complete rectal excision should be amenable to anterior or low anterior resection. Low anterior resection is a less morbid procedure with which most surgeons have a fairly extensive experience. For extremely large tumors that extend to the dentate line, coloanal anastomosis is appropriate. The functional results are acceptable compared with the alternative of abdominoperineal resection. Abdominoperineal resection should be reserved for those patients with a diagnosis of invasive carcinoma in whom a lesser procedure would not constitute adequate treatment.

Modifying the environment: a community-based injury-reduction program for elderly residents

The Department of Public Health, City and County of San Francisco, established the Community and Home Injury Prevention Program for Seniors (CHIPPS) to reduce the rate of unintentional injuries among elderly residents. Through a collaboration between the CHIPPS program, the University of California at Berkeley School of Public Health and the University of California at San Francisco School of Medicine, we tested the hypothesis that providing minor home safety modifications would reduce rates of falls, scalds, and burns. A one-group, pretest-posttest design was used to compare self-reported falls, scalds, and burns for six-month periods before and after the intervention. The intervention used 10 person-hours of unskilled labor and $93 worth of materials on average and included home safety assessments and modifications such as removing clutter; installing hand rails, grab bars, nonskid strips; and securing rugs and electrical cords. Reported falls were reduced by 60% after the intervention, from 0.81 to 0.33 falls per person year (p < .01). Scalds were reduced from 9 to 0 (P < .01) and burns from 7 to 0 (P < .02) during the six-month periods before and after the intervention. Some of the apparent effect may be due to differential reporting. This community-based program to reduce hazards in the home environments of senior citizens was feasible, well accepted, and probably effective in preventing falls, burns, and scalds. Medical Subject Headings (MeSH): accidental falls/prevention and control, aged, safety.

Postpolypectomy colonic hemorrhage

PURPOSE

This study was undertaken to evaluate the incidence, diagnostic methods, and treatment of hemorrhage occurring after colonoscopic polypectomy.

METHODS

A retrospective chart review was conducted of 12,058 patients who underwent colonoscopy at an academic referral center between January 1989 and July 1993. Of these, 6,365 patients required polypectomies or biopsies.

RESULTS

After these procedures, 13 patients (0.2 percent) developed lower gastrointestinal hemorrhage requiring hospitalization. All bleeding episodes occurred within 12 days of polypectomy or biopsy (mean = 8 days). Twelve patients (92 percent) underwent technetium-tagged red blood cell scintigraphy, which localized bleeding in four patients (31 percent). In the eight patients with normal scintigrams, hemorrhage did not recur, and no further evaluation was performed. Five patients (38 percent) underwent arteriography. Arteriogram was positive in two of four patients with positive scintigrams, and bleeding was controlled with selective vasopressin infusion. The fifth patient had arteriography without prior diagnostic studies because of massive hemorrhage; the bleeding site was identified and controlled with selective vasopressin infusion. Three patients had lower gastrointestinal endoscopy, with endoscopic identification of bleeding site in two patients, and endoscopic electrocautery controlled the bleeding in one patient. In the 13 patients with hemorrhage, cessation of bleeding occurred with intestinal rest and hydration in nine patients (69 percent), selective vasopressin infusion in three patients (23 percent), and endoscopic electrocautery in one patient (8 percent). Eight patients (62 percent) required blood transfusion with a mean of 4.8 units (excluding one patient on warfarin sodium who required 14 units of blood). No patient required surgical intervention.

CONCLUSIONS

Incidence of hemorrhage after colonoscopic polypectomy or biopsy is low, and in our series, hemorrhage resolved without the need for surgical intervention. Management includes initial stabilization followed by diagnostic evaluation. Technetium-tagged red blood cell nuclear scintigraphy identifies ongoing bleeding and identifies patients in whom additional invasive procedures (arteriography lower gastrointestinal tract endoscopy) are warranted.

Colostomy closure. Ochsner Clinic experience

PURPOSE

We retrospectively reviewed the records from our past five years of experience with colostomy closure at a large multispecialty hospital to determine postoperative morbidity.

RESULTS

From March 1988 to April 1993, 46 patients underwent colostomy closure. Patients ranged in age from 24 to 87 (mean, 41.8) years, and 25 (54 percent) were women. Stomas had been created during emergency operations in 40 patients (87 percent); most operations (54 percent) were for complications of acute diverticulitis. Of the 46 procedures, 40 (87 percent) were end colostomies, and 6 were loop colostomies. Stomas were closed at a range of 11 to 1,357 days after creation (mean, 207 days; median, 116 days). Twenty-six patients (57 percent) underwent colostomy closure alone, and the remainder underwent additional procedures ranging from appendectomy to hepatic lobectomy. Duration of operations ranged from 1 to 9.5 (mean, 4.2) hours, and estimated blood loss averaged 400 ml. Overall hospital stay for closure was 6 to 62 (mean, 11.5) days. Inpatient complications occurred in 15 percent of patients, including congestive heart failure (2 percent), cerebrovascular accident (4 percent), pneumonia (2 percent), enterocutaneous fistula (2 percent), and pulmonary embolus with death (2 percent). The most common long-term complication was midline wound hernia, which occurred in 10 percent of surviving patients. Overall, complications occurred in 24 percent.

CONCLUSIONS

Colostomy closure is a major operation; however, with good surgical judgement and technique, associated morbidity and mortality can be minimized.

Colon surveillance after colorectal cancer surgery

PURPOSE

This study was performed to determine cost-effective colonoscopy guidelines for patients with prior colorectal adenocarcinoma.

METHOD

A retrospective review was performed of patients who had been treated for colorectal adenocarcinoma and later underwent follow-up colonoscopy from 1984 to 1994.

RESULTS

During this study period, 389 patients previously treated for colorectal adenocarcinoma underwent follow-up colonoscopy. All patients had perioperative colon evaluation for other neoplasms. Ages ranged from 26 to 89 (mean, 65.8) years, and 46.8 percent were female. Recurrent or metachronous cancer or a neoplastic polyp constituted a positive examination. Results of 389 first follow-up colonoscopies were compared with 259 second (66.6 percent), 165 third (42.4 percent), and 83 fourth (21.3 percent) follow-up examinations. Median interval between all colonoscopies was 13 months. Positive examination rates for the first two yearly examinations were 18.3 and 18.5 percent, respectively. Slightly lower, third-year and fourth-year positive examination rates were 16.4 and 14.5 percent, respectively. Four-year examinations yielded the following: first year--1 carcinoid, a new adenocarcinoma, and 100 polyps; second year--1 anastomotic recurrence and 68 polyps; third year --55 polyps; and fourth year--1 recurrent cancer and 17 polyps.

CONCLUSIONS

These data suggest that 1) annual follow-up colonoscopy for two years after colorectal cancer surgery is beneficial for detecting recurrent and metachronous neoplasms and 2) the interval between subsequent examinations may be increased depending on the result of the most recent examination.

Fecal seepage and soiling: a problem of rectal sensation

PURPOSE

To determine the physiologic alteration resulting in fecal seepage and soiling, results of anorectal manometric testing were evaluated in patients with varying degrees of fecal incontinence.

METHODS

Anal manometric studies performed on 170 patients with fecal incontinence were reviewed. Results of their studies, including mean resting pressure, maximum resting pressure, maximum squeezing pressure, minimum rectal sensory volume, and minimum volume at which reflex relaxation first occurs, were compared with those of 35 control group subjects with normal fecal continence. Manometric studies were performed using a four-channel, water-perfused catheter. Incontinent patients were divided into three groups based on presenting complaints: complete incontinence (incontinence of gas and liquid and solid stool), partial incontinence (incontinence of gas and liquid), and seepage and soiling (incontinence of small amounts of liquid and solid stool without immediate awareness).

RESULTS

Resting pressures were significantly lower in complete incontinence, partial incontinence, and seepage and soiling groups than in the controls (P < 0.001). Resting pressures of the complete incontinence group were also significantly lower than those of the partial incontinence and seepage and soiling groups (P = 0.03). Squeezing pressures were lower for both the complete incontinence and partial incontinence groups than for those in the control group (P < 0.001) and in the seepage and soiling group, which did not differ significantly from controls. The minimum rectal sensory volume was greater in all incontinent groups than in controls (P < 0.001). Sensory volume of the seepage and soiling group was significantly greater than that of the complete incontinence and partial incontinence groups (P < 0.01). The difference between sensory volume and the volume producing reflex relaxation was greatest in the seepage and soiling group and differed from that of the partial incontinence and control groups.

CONCLUSIONS

These findings suggest that the mechanism of incontinence is different in seepage and soiling patients and involves a dyssynergy of rectal sensation and anal relaxation. Patients with the pattern of seepage and soiling may be successfully treated with stool bulking agents (e.g., psyllium or bran).

Colonoscopic follow-up of adenomas and colorectal cancer

Increasing experience with colonoscopy has altered recommendations for the frequency of follow-up surveillance examinations for adenomatous polyps and colorectal cancer. Current recommendations include a follow-up colonoscopy at 1 year for patients with more than two adenomatous or highly suggestive polyps and after curative surgery for colorectal cancer. Other patients can safely receive a follow-up colonoscopy at longer intervals of 3 years. Published data and a review of the Ochsner Clinic experience are presented to support these recommendations.

Combination therapy for epidermoid carcinoma of the anal canal

PURPOSE

This study was designed to assess results of chemoradiation therapy for epidermoid carcinoma of the anal canal.

METHODS

A retrospective review of records of the prospective database revealed 35 patients who had been diagnosed with anal canal carcinoma and treated with chemoradiotherapy at Wilford Hall USAF Medical Center (tertiary referral hospital) from 1981 to 1991.

RESULTS

Patients ranged in age from 35 to 80 (mean, 59) years, and 63 percent were women. Primary tumors ranged from 1 to 8 cm in diameter (mean, 3 cm). The first six patients had an abdominoperineal resection (APR) after chemoradiotherapy, and no residual tumor was identified in the specimens. In the subsequent 29 patients who did not have APR, 5 had moderate problems with anal continence, and one required a diverting colostomy for incontinence. Follow-up ranged from 4 months to 12.9 years (mean, 5.2 years). There were two pelvic recurrences, and three patients developed distal metastasis. Eight patients died during follow-up, including three with recurrent or persistent disease. Five-year survival using life-table analysis was 89 percent.

CONCLUSION

Long-term follow-up confirms that chemoradiation remains the preferred therapy for epidermoid carcinoma of the anal canal.

Colorectal operative experience. Results of a survey

PURPOSE

This study was designed to document the operative colorectal experience of members and fellows of The American Society of Colon and Rectal Surgeons.

METHODS

A mail survey of 900 members and fellows of The American Society of Colon and Rectal Surgeons was conducted.

RESULTS

One hundred eighty questionnaires (20 percent) were returned; however, 25 respondents had retired or lacked accurate operative data. The remaining 155 surgeons averaged 49 (range, 35-83) years in age and had been in practice an average of 14.7 (range, 2-51) years. The respondents performed a median of 135 and a mean of 177 anorectal procedures per year (range, 20-1,471) and a median of 67 and a mean of 79 abdominal colorectal procedures (range, 6-443). Operative hemorrhoidectomy was the most common anorectal procedure (median, 25; mean, 47/year), while partial colectomy was the most common abdominal procedure (median, 18; mean, 26). The number of anorectal procedures correlated directly with the respondents' time in practice, and the number of abdominal procedures peaked between the tenth and fifteenth years.

CONCLUSION

Despite the limitations associated with this type of study, the information is useful in assessing practice patterns and experience level.

Ulcerative colitis: surgical indications and alternatives

Ulcerative colitis is a surgically curable mucosal disease of the colon and rectum. Optimal management of this chronic condition requires close coordination between the patient, surgeon, and primary care provider or gastroenterologist. Knowledge of surgical indications and the operative alternatives available helps to individualize therapy. Acute and chronic indications for surgery and the five surgical methods currently in use are described.

Nonpalpable breast lesions: association of mammographic abnormalities with diagnosis after needle-directed biopsy

We reviewed the experience with needle-directed breast biopsies (NDBB) in a military medical center. In 195 patients, 207 NDBBs were done; 49 of these biopsies (24%) rendered a diagnosis of malignancy. The majority of patients (78%) had invasive cancer; 44% of them were found to have associated malignant axillary adenopathy. Mammographic indications were examined; 65% of the biopsies were done for microcalcifications with or without an associated mass/density. Approximately one third of these lesions harbored malignancy or high-risk hyperplasia. Discrete nodular densities had a low rate of malignancy (7%), while spiculated/stellate masses proved almost uniformly to be invasive cancer. NDBB should be considered in all women with mammographic abnormalities. The associated risk of malignancy may vary depending on the specific mammographic appearance of the lesion. Unfortunately, a significant number of women may have relatively advanced malignancy when first seen, despite having nonpalpable disease.

Laparoscopic-assisted full-thickness endoscopic polypectomy

PURPOSE

To describe the procedure for endoscopically removing sessile colonic polyps with laparoscopic assistance.

METHODS

Technique description and retrospective review of experience.

RESULTS

The technique has been used to successfully remove polypoid colonic lesions in three patients.

CONCLUSIONS

Laparoscopic-assisted polypectomy allows complete excision of moderate-sized sessile polyps and may spare selected patients a colonic resection.

Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique

Surgeons have developed many methods for the repair of direct inguinal hernias. The Cooper's ligament (McVay) repair and the Shouldice repair are widely used techniques. To determine the recurrence rates with differing techniques performed in a surgery residency program, we conducted a prospective randomized study for elective adult direct inguinal herniorrhaphies. Three hundred and eight elective direct inguinal herniorrhaphies in 269 adult patients were performed by residents in general surgery supervised by staff surgeons. Patients had yearly follow-up physical examinations (compliance rate of 87 percent) during an average follow-up period of 36.4 months. The recurrence rate was 8.8 percent for the McVay repair and 6.6 percent for the Shouldice repair (not significant). Bilateral inguinal hernias (repaired six weeks apart) had a recurrence rate of 12.8 percent, while the recurrence rate for unilateral repairs was 5.6 percent (p = <0.05). We found no significant difference in recurrence rates between the McVay and Shouldice herniorrhaphy techniques. However, there was an increase in hernia recurrence with either technique when bilateral direct inguinal herniorrhaphies were performed.

Simplified balloon expulsion test

The balloon expulsion test is a simple and inexpensive method to evaluate a patient's ability to expel and retain stool. In conjunction with other methods, it assists in identifying patients with outlet obstruction or incontinence. A simplified method of performing a balloon expulsion test is described.

A new oral lavage solution vs cathartics and enema method for preoperative colonic cleansing

Sulfate free-electrolyte lavage solution is a new osmotically balanced electrolyte gut lavage solution for colon surgery that has been formulated for improved taste and reduced water and electrolyte changes. Sixty patients were prospectively randomized to receive a 1-day preparation with sulfate free-electrolyte lavage solution or a 3-day preparation using a clear liquid diet, cathartics, and enemas. The patient groups were similar in age, race, male-female ratio, and the types of colonic resections performed. Colonic cleansing was better with sulfate free-electrolyte lavage solution (100% vs 63% "good" to "excellent" cleansing). Patient tolerance evaluated by a questionnaire showed more overall discomfort with sulfate free-electrolyte lavage solution but no difference between the preparations in individual symptoms of fullness, cramping, nausea, or vomiting. One patient developed a low level of serum potassium after a cathartic and enema preparation, while there were no complications with sulfate free-electrolyte lavage solution. Patient taste questionnaires showed a slight preference for sulfate free-electrolyte lavage solution (53%) over a polyethylene glycol electrolyte lavage solution (47%). This study confirms that sulfate free-electrolyte lavage solution is a safe and effective method of preoperative colonic cleansing.