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Safety of prone jackknife position in ambulatory anorectal surgery
Fareed Cheema, Sabair Lee, Marcus Zebrower, Juan Lucas Poggio
October-December 2018, 7(1):16-19
Background and Objectives: The objectives of this study were to determine morbidity and mortality rates of ambulatory anorectal surgeries in prone jackknife position. Patients and Methods: Retrospective chart analysis on 210 patients undergoing ambulatory anorectal surgery in the prone jackknife position. The primary endpoint studied was mortality and complication rates. Other factors analyzed were age, sex, clinical diagnosis, procedure, past medical history, American Society of Anesthesiologists physical status classification, current smoking status, mean pre- and post-operative mean arterial pressure (MAP), mean minimum intraoperative MAP, minimum intraoperative O2saturation, estimated blood loss, fluids given, anesthesia duration, antibiotic administration, and days to discharge and whether there were any readmissions within 30 days. To assess significant differences between pre-, intra-, and post-operative mean arterial pressure, one-way ANOVA was used. Results: There was no mortality within 30 days of surgery. Complication rate was 3.3% with urinary retention being the most common, comprising 42% of all complications. Thirty-day readmission rate from surgery was 1%. Mean pre- and post-operative MAP was 88.4 ± 11.4 and 90.6 ± 11.9, respectively. Mean minimum intraoperative MAP and O2saturation was 70.6 ± 9.5 and 98.7% ± 1.6%, respectively. Mean minimum intraoperative MAP was significantly decreased compared to mean pre- and post-operative MAP (P < 0.05). Conclusion: Prone jackknife position supports the chest while relaxing the abdomen by flexing at the hips. In ambulatory anorectal surgeries under general anesthesia, given the hemodynamic stability and lack of intra- and post-operative complications, prone jackknife position is a noninferior alternative to supine or lithotomy position.
  5,396 299 -
Mucosal advancement flap for fistula-in-ano: A single-institution experience
Yui Kaneko, David Lam, James Keck, Rodney Woods
October-December 2018, 7(1):12-15
Background and Objective: Mucosal advancement flap (MAF) is a well-described definitive treatment for complex fistula-in-ano, with high healing rates ranging from 37 to 87% for cryptoglandular fistula, but with mild incontinence rates of up to 35%. There is a paucity of Australian data to support the efficacy and complication rates of MAF, nor predictive factors for success. Patients and Methods: This was a retrospective study, with ethical approval granted by St. Vincent's Hospital Melbourne (SVHM) Quality and Risk Unit. Patients who underwent MAF at SVHM and St Vincent's Private Hospital Fitzroy from 2011 to 2015 were included in the study; all data were collected from patient medical records. Results: A total of 65 patients were treated with MAF during the study period. Fistula etiology was cryptoglandular in 82%, anovaginal in 11%, and perianal Crohn's disease in 7% of patients. Overall success rates for MAF were 66% for cryptoglandular fistula, 14% for anovaginal fistula, and 40% for Crohn's fistula. Excluding anovaginal fistulae, the success rate of MAF was 74% for males and 57% for females. MAF performed for an anterior internal opening was associated with a success rate of 65% versus 56% for a posterior internal opening. Postoperative fecal incontinence rate was 6%. Five of the patients with failed MAF underwent a second sphincter-preserving procedure; none of these were successful. Conclusion: This study supports the use of MAF for the treatment of complex fistula-in-ano, with a success rate compatible with existing literature and a low incontinence rate.
  3,158 370 -
Rare complication of a common disease: Coccygeal osteomyelitis following Pilonidal sinus
Mugdha Kowli, Pranav Mandovra, Gautam Zaveri, Roy Patankar
January-March 2019, 8(1):27-29
Pilonidal sinuses commonly arise in the sacrococcygeal region. The common complications are local cellulitis, abscess formation which is related to the infectious process, and recurrence after surgery. They rarely evolve with osteomyelitis, meningitis, or malignant transformation. Coccygeal osteomyelitis as a direct complication of sacrococcygeal pilonidal sinus disease (PSD) is extremely rare with limited data. We report a case of complicated sacrococcygeal PSD with coccygeal osteomyelitis. It was managed with: wide local excision of the pilonidal sinus, coccygectomy, perineal musculature reconstruction, and defect closure by Limberg rhomboid flap.
  2,752 152 -
Transcutaneous posterior tibial nerve stimulation for fecal incontinence: New hope revisited
Ahmed A Khalil, Essam F Ebeid, Tarek Y Ahmed, Karim F Elneklawy, Mohamed A Nada
October-December 2019, 8(4):98-101
Background: Neuro-modulation of the pelvic nerves is an effective and promising modality for treating fecal incontinence. Direct sacral nerve stimulation is the most popular for neuro-modulation although it is technically demanding. Percutaneous and transcutaneous posterior tibial nerve stimulations are relatively newer approaches for neuro-modulation and they carry the advantage of being cheaper and less invasive. There is not much published data about the transcutaneous approach and in this study, we are describing our experience with this technique. Objective: This study was conducted to describe and determine the efficacy of percutaneous posterior tibial nerve stimulation in the treatment of fecal incontinence. Design: A prospective descriptive study. Setting: The colorectal clinic in the hospital was prepared with the required equipment. The authors funded all procedures performed and the patients paid no extra charges. Patients and Methods: Our study included 15 patients with fecal incontinence visiting the colorectal clinic in Ain Shams University Hospital. All patients received 12 sessions of electric stimulation, 3 sessions per week for 40 minutes each. Main Outcome Measures: Sample Size Wexner score and the short term effect of the treatment. Sample Size: 15 patients. Results: The study included 11 females and 4 males, 2 patients were excluded from the results. The results showed that there was improvement in mean Wexner score for these patients from 13 before the treatment to 8 after finishing the treatment course. Reassessment after 6 months of treatment revealed no deterioration in their continence. Conclusion: We found that transcutaneous posterior tibial nerve stimulation is an effective, cheap, and tolerable method for treating fecal incontinence. However, long-term follow up is required on larger group of patients to adopt this technique. Limitations: Small sample size, short course follow up.Conflict of Interest: None.
  2,442 112 -
Colon and rectal surgery for inflammatory bowel disease patients on vedolizumab: Preliminary surgical outcomes
Sarah B Stringfield, Lisa A Parry, Sonia L Ramamoorthy, Samuel G Eisenstein
October-December 2018, 7(1):1-7
Background and Objectives: Vedolizumab is an antagonist of leukocyte trafficking that targets gut α4β7 integrins and is efficacious in inflammatory bowel disease (IBD). Studies investigating postoperative complications in patients on this medication have not been performed. The objective of this study is to identify rates and types of postoperative complications experienced in patients with IBD who have undergone surgery following treatment with vedolizumab. Patients and Methods: This was a retrospective review of the electronic medical record of patients with IBD who underwent perianal or abdominal surgery, June 2014–March 2016, at the University of California San Diego Medical Center. Main outcome measures were rates and types of postoperative complications. Results: Patients were divided into three treatment groups: vedolizumab, other biologics, and no biologics. Twenty-nine patients on vedolizumab underwent forty operations that fit study criteria. Fifteen of 26 abdominal operations experienced a postoperative complication, for a complication rate of 57.7%. The most common complication was infectious (34.6%). Anastomotic leak rate was 16.7% and mortality rate was 7.7%. Complication rates in patients on vedolizumab were higher than rates in other patients with IBD. One of 14 perianal operations experienced an infectious complication (7%). Readmission rate in abdominal patients on vedolizumab was higher than the other categories (31% vs. 7% and 10%, P = 0.01). Conclusions: We observed high rates of postoperative complications in patients on vedolizumab who underwent abdominal surgery. Rates were higher than published outcomes as well as outcomes for other IBD patients at our institution. Studies including larger numbers of patients must be performed to further investigate this issue.
  2,173 319 -
Is Laparoscopic Hartmann's Reversal a Safe Option? A Systematic Review and Meta-Analysis
Joseph C Kong, Glen R Guerra, Swetha Prabhakaran, Satish K Warrier, Alexander G Heriot
October-December 2020, 9(4):57-63
Background: Hartmann's reversal is a major operation to restore colorectal continuity. Traditionally, an open Hartmann's reversal (OHR) has been performed but there is a trend toward performing laparoscopic Hartmann's reversal (LHR). With the increasing number of publications comparing these two, it is important to ascertain whether the benefits of LHR outweigh the risks. Objective: To compare LHR and OHR with respect to morbidity and mortality rates. Design: A systematic review and meta-analysis. Setting: The study was conducted at the Peter MacCallum Cancer Centre in Melbourne, Australia. Patients and Methods: A detailed systematic search was performed through PubMed, SCOPUS, TRIP, EMBASE, and ClinicalKey from 1990 to October 26, 2016. A review was undertaken in accordance with PRISMA guidelines. Main Outcome Measures: The primary outcome measure was 30-day morbidity. Secondary outcome measures included estimated intraoperative blood loss, conversion from laparoscopic to open approach, length of hospital stay, and 30-day mortality. Sample Size: Eighteen eligible studies were identified, comprising a total of 7824 patients: 1586 in the laparoscopic group and 6238 in the open group. Results: There was no statistical difference in mean operative time between the two groups. Overall morbidity was lower in the LHR group (16.8% vs 23.7%, P < 0.0001). Subgroup-analysis showed a higher risk of sepsis (6.5% vs 3.2%; P < 0.0001), wound infection (22.5% vs 12.6%; P < 0.0001), and ileus (13.4% vs 5.5%; P = 0.001) in the OHR group. Conclusion: LHR was associated with a lower morbidity rate and shorter hospital stay with an equivalent operative time. There is a moderate rate of conversion and appropriate case selection is important. Limitations: An absence of prospective or randomized trials comparing the two approaches for Hartmann's reversal, contributing to selection bias in our study. It was difficult to combine patient characteristics data due to the heterogeneity in the reported parameters. Conflict of Interest: None.
  2,001 218 -
Back to basics – The importance of enterostomal therapy education for general surgery residents
John J Tackett, Annabelle L Fonseca, Walter E Longo
October-December 2018, 7(1):8-11
Background and Objectives: General surgery residents' perceived knowledge base and comfort with intestinal stomas and enterostomal therapy are profiled through a national survey. Subjects and Methods: General surgery residents were surveyed to explore the existence of formal didactics and training in ostomy creation and stomal care, to examine the residents' perceived knowledge base of clinical indications for enterostomal care approaches, and to elicit the residents' comfort with performing enterostomal surgeries and managing complications. Results: A total of 734 US residents were surveyed. 218 respondents completed the survey (30%): 40% Northeast, 22% Midwest, 22% South, 16% West, and 82% with direct university affiliation. Only 12% experienced formal enterostomal therapy training and only 15% attended related lectures. Most (86%) routinely worked with enterostomal therapists. Only 11% of chiefs felt “very confident” in their knowledge base of clinical indications for enterostomal care, and 61% felt “very comfortable” with surgical procedures of ostomy creation and closure. Merely 4% of all residents felt “very comfortable” dealing with common ostomy complications. Conclusions: In an era of surgical subspecialization and advanced nursing practice in enterostomal therapy, general surgery residents lack confidence in their knowledge base and comfort when approaching enterostomal therapy and stomal complications. US resident education should be reformed to enhance training in these fundamental principles essential to general surgery practice.
  1,881 326 -
#Colorectalsurgery: Connecting colorectal surgeons around the world
Sameh Hany Emile, Hossam Elfeki
October-December 2018, 7(1):20-21
  1,947 229 -
Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery?
Ashley M Tameron, Amy E Murphy, Lala R Hussain, David Lee, Hamza Guend
January-March 2019, 8(1):10-13
Background: Colonic volvulus is a rare cause of bowel obstruction with an incidence of 2%–10%. Cecal volvulus accounts for 10%–40% of cases, with a mean age of 53 years. There is a paucity of literature reporting how older patients with cecal volvulus fair relative to their younger counterparts. Objective: The goal of our study is to evaluate the outcomes after surgical resection in patients ≥50 years old with cecal volvulus. Design: The design of the study was to collect the National Surgical Quality Improvement Program (NSQIP) data and analyze primary outcomes. Settings: These data were collected from NSQIP database focusing on patients with cecal volvulus. Materials and Methods: We utilized the NSQIP database. We identified volvulus by ICD-9 code 560.2. We selected patients with cecal volvulus who underwent surgical resection by specifying the CPT codes for open and laparoscopic right hemicolectomy. Main Outcome Measures: The primary outcomes were mortality and major and minor postoperative complications. Student's t-test was used to compare continuous variables. Chi-square and Fisher's exact tests were used to compare categorical variables. Sample Size: Analyzing the NSQIP database from 2010 to 2015, 1220 patients were identified. Results: 21.8% of patients were <50 years old and 78.2% were ≥50 years old. Patients aged ≥50 years had higher rates of comorbid conditions. There was no significant difference in mortality between the two groups or major and minor complications. Patients aged ≥50 years had a longer length of total hospital stay, i.e., days from operation to discharge. Conclusion: Cecal volvulus is an uncommon reason for bowel obstruction with unclear outcomes in elderly patients in the literature. Our study demonstrates no differences in outcomes after surgical intervention for cecal volvulus. Limitations: Limitations of this study include large database collection and selection bias. As we specifically included right hemicolectomy, this excludes patients who underwent nonresection intervention.
  1,724 190 -
Evaluating the efficacy of biofeedback for chronic constipation using the constipation severity instrument and constipation-related quality of life measure
Yuan-Tzu Lan, Lillian G Jahan, Madhulika G Varma
January-March 2019, 8(1):4-9
Background: Many studies have described using biofeedback to treat chronic constipation, but few reports have addressed its impact on quality of life (QOL). Objective: The aim was to evaluate the effect of biofeedback with a validated Constipation Severity Instrument (CSI) and Constipation-Related QOL (CRQOL) measure. Design: Prospectively collected data with retrospective analysis. Setting: Tertiary care academic center. Patients and Methods: Patients referred to the Center for Pelvic Physiology with chronic constipation and objective signs of pelvic floor dyssynergia, who received a complete course of biofeedback therapy and returned all of their questionnaires, were enrolled in the study. Questionnaires were given upon initial evaluation, immediately after the complete course of biofeedback, and 6 months later. Main Outcome Measures: Improvement of dyssynergia symptom and QOL by CSI and CRQOL. Sample Size: A total of 25 patients (20 females and 5 males) were included. Results: Overall, 75% of patients reported satisfactory symptom and QOL improvement. CSI total scores decreased after treatment (35.0 vs. 31.0, P = 0.06) and at 6-month follow-up (35.0 vs. 30.0, P = 0.05). Only the obstructive defecation (OD) subscale of CSI improved significantly after treatment (median 21.0 vs. 16.5, P < 0.01) and sustained to 6 months after therapy (median 21.0 vs. 18.5, P = 0.03). Statistically significant improvement was seen in the distress subscale of the CRQOL immediately after biofeedback (24.0 vs. 18.0, P = 0.02). Conclusions: This study demonstrated that the active effects of biofeedback in constipated patients were specific to OD symptoms and the distress subscale for QOL. CSI and CRQOL are both useful tools to evaluate the specific response of constipated patients after biofeedback therapy. Limitations: The study limitation was the small sample size due to difficulty in obtaining complete information in the enrolled patients.
  1,600 217 -
Curative management of malignant left-sided colorectal obstruction
Wen-Shen Lee, Joseph C Kong, Peter Carne, Stephen Bell, Satish K Warrier
April-June 2019, 8(2):35-39
Left-sided malignant colonic obstruction remains a challenging surgical problem despite recent advances. We aim to provide a concise overview of the relevant surgical options for this condition in the curative setting. A literature search of MedLine, PubMed, and Embase was performed to elucidate the latest evidence in the management of malignant left-sided colorectal obstruction, focusing on the risks and benefits of each approach and the appropriate patient selection. Primary resection and anastomosis are the intervention of choice for low-risk patients in the curative setting. Delayed resection with a bridge to surgery should be considered in unwell patients requiring medical optimization. While stenting has gained popularity, the risk of stent perforation carries a poor prognosis and must be carefully considered. Hartmann's procedure should be considered in high-risk elderly patients. Subtotal colectomy is preferred over segmental colectomy when there is extensive proximal colon damage but results in more frequent bowel actions postoperatively.
  1,517 243 -
The hanging pouch
Daniel J Wong, Michael Q Tran, Vitaliy Y Poylin
January-March 2019, 8(1):22-23
Ileoanal pouch reconstruction can be complicated intraoperatively by the inability for the pouch to reach the anus in a tension-free manner. Here, a case is presented where standard “mesentery lengthening” procedures did not allow the pouch to reach the anus and thus the pouch was left hanging in situ resulting in pouch lengthening over several months and a successful anastomosis at a later date.
  1,459 150 -
Surgical strategies to reduce recurrence in Crohn's disease
Charlotte Austin, Randolph M Steinhagen
January-March 2019, 8(1):1-3
Almost from the time of initial description of Crohn's disease 85 years ago, it has been known that surgical resection is not curative. The disease invariably recurs. Over this period of time, numerous strategies have been proposed in an attempt to reduce the recurrence rate, or delay the development of recurrent disease. The purpose of this review is to examine a number of strategies and to evaluate their effectiveness. It also aims to look at what might lie ahead in the future. This review consists of an English language literature search to identify previous studies that have proposed various surgical strategies to reduce the recurrence rate following surgery for Crohn's disease. A number of surgical strategies have been proposed including widening the resection margins, changing the type of anastomosis, use of laparoscopy, and most recently, resecting wide mesenteric margins. To date, none of these strategies has proven to be effective in reducing recurrence rates. Although a surgical strategy to reduce recurrence in Crohn's disease has not been identified, there are currently investigators looking at other possibilities that may be shown to be effective in the future.
  1,357 238 -
Right versus left Colon cancer: Is there a difference in outcomes?
Aris Plastiras, Evangelia Iosif, Georgia Georgiou, Amyn Haji, Asif Haq, Savvas Papagrigoriadis, Joseph W Nunoo-Mensah
January-March 2019, 8(1):14-21
Background: Colorectal cancer is a major healthcare problem due to its high prevalence and mortality rates. Objective: The objective of the study is to delineate the relationship between the location of the colon cancer and the outcomes. Design: This is a retrospective, single-center study including patients diagnosed with right and left colon cancer from January 2010 to December 2015. Setting: Patients with no rectal or synchronous metastatic disease were included in the study. Diagnosis was confirmed following a computed tomography and colonoscopy. Patients and Methods: Four hundred and seventy-five patients with colon cancer were included; 226 right-sided tumors (RCC) and 249 with left-sided colon cancer (LCC) underwent surgery. Main Outcome Measures: We compared right- and left-sided tumors in terms of epidemiological, histological, clinical, and perioperative characteristics, and we also attempted to determine whether there is a difference in the overall and per stage survival. Sample Size: Four hundred and seventy-five patients with colon cancer. Results: Patients with colon cancer were analyzed, 226 (47.5%) with RCC and 249 (52.4%) with LCC underwent surgery. Patients with RCC were more likely to be women, older, and with more comorbidities. Furthermore, RCC were more likely to be poorly differentiated (29.65%, P < 0.001) and more locally advanced at the time of diagnosis (P < 0.001). Controlling the differentiation for each stage, there was no statistical significant difference between left and right survival and recurrence (P > 0.05). When stratified according to tumor stage, Stage II LCC had better overall survival (odds ratio [OR], 1.694, 95% confidence interval [CI], 1.015, 2.827) and Stage III LCC had a better overall survival (OR, 1.403, 95% CI, 1.007, 2.143), disease-free survival (OR, 1.293, 95% CI, 1.011, 1.714), and less cancer-related deaths (OR, 0.282, 95% CI, 0.080, 1.000). Conclusions: Comparing similar stages, patients with LCC appear to have better oncological outcomes irrespective of tumor differentiation. Limitations: Single-center, retrospective study without excluding patients with hereditary cancers. Oncological biomarkers were not available in all patients, and further analysis was not performed.
  1,360 212 -
Leiomyoma of the sigmoid mesocolon associated to hemorrhagic infarct and high count of mast cells
Carlo Lozano-Burgos, Claudio Etcheverry-Pizarro, Wilfredo Alejandro González-Arriagada, Paola Ochova-Gallardo
January-March 2019, 8(1):24-26
Leiomyoma is a soft-tissue benign tumor and its occurrence in the mesocolon is extremely rare. We present a particular case of a leiomyoma of the sigmoid mesocolon of a 58-year-old man, associated to a hemorrhagic infarction treated surgically and without recurrences after 1 year of follow-up. The macroscopic, histopathologic, and immunohistochemical features are presented and discussed. The high mast cell count associated with a low rate of cell proliferation is a sign of the benign biological behavior in this entity and may be helpful hallmarks for the differential diagnosis with other gastroenterological neoplasia.
  1,366 198 -
Role of local infiltration of methylene blue as an analgesic in stapled hemorrhoidopexy: A prospective study
Pranav Mandovra, Vishakha Kalikar, Prasang Bajaj, Roy Patankar
January-March 2020, 9(1):10-13
Background: Stapled hemorrhoidopexy gained popularity due to low postoperative pain. Few patients still complain of postoperative anal pain. Methylene blue (MB) in caudal and epidural anesthesia gives long-term pain relief and has also been used to treat intractable pruritus ani. Objective: Evaluate the role of local infiltration of the MB as an analgesic in the procedure for prolapse and hemorrhoids (PPH) surgery. Design: Prospective observational study. Setting: Tertiary health care center. Patients and Methods: Patients with grade-III hemorrhoids were included and were divided into two groups: A and B. Group A received a perianal injection of 2 mL of 1% MB with 10 mL of 25% bupivacaine. Group B received a perianal injection of 2 mL of normal saline with 10 mL of 25% bupivacaine. Main Outcome Measures: Patients were followed up prospectively for pain, hospital stay, and complications. Results were noted and compared between the two groups. Sample Size: 50 patients. Results: Group A had significantly lower pain scores on day 3 (mean ± SD 2.08 ± 1.08) and day 7 (mean ± SD 0.64 ± 0.95) as compared to the pain scores on day 3 (mean ± SD 3.92 ± 1.35) (P-value = 0.000) and day 7 (mean ± SD 2.40 ± 1.0) (P-value = 0.000) in group B. Pain scores within first 24 h and day 21 post-surgery were not statistically significant between groups A and B (P-value = 0.286 and 0.19, respectively). Group B required a significantly higher number of both injectable and oral analgesics (mean + SD 4.03 + 0.94) as compared to group A patients (mean + SD 1.97 + 0.81) (P-value = 0.001). 4% of the patients in group B had prolonged hospital stay due to severe pain. Patients in group A also had a significant reduction in their requirement of analgesics. None of the patients who received MB had any local or systemic allergic reactions. Conclusion: Local infiltration of MB may be used as an effective analgesic in PPH patients without any increase in morbidity. Limitations: Single-center study with a small sample size. Conflict of Interest: None.
  1,358 191 -
Trends in survival after colorectal cancer surgery in an Australian regional hospital
Suat Chin Ng, Douglas Stupart, David Watters
April-June 2019, 8(2):40-43
Background: Colorectal cancer(CRC) is the second most common cancer in Australia. Improvements in patient outcomes after resections for CRC have been reported in an Australian metropolitan hospital, but significant outcome variability exists between health systems and institutions. Objective: This study sought to determine whether changes in the management of CRC have translated into improved survival after surgery in an Australian regional hospital. Design: This is a retrospective study of a prospectively maintained database. Setting: This study was conducted in an Australian regional hospital. Patients and Methods: All patients who underwent surgery for CRC at our institution between January 2002 and December 2014 were studied. Demographic information, comorbidities, types of surgery performed, and tumor staging were recorded. Patients were followed up for life whenever possible. Survival analysis was done using the Kaplan–Meier method, and comparisons made using the Cox proportional-hazards method. Chi-squared test was used to compare categorical data and look at trends as appropriate. P ≤ 0.05 was considered statistically significant. Statistical analysis was done using Medcalc®(Mariakerke, Belgium) software. Main Outcome Measures: Primary outcome measures the survival trends for CRC patients in regional center, Victoria. Secondary outcomes measure the short-term results, including perioperative mortality and anastomotic leak rate. Sample Size: A total of 1079patients who underwent surgery for CRC over13years were studied. Results: There were 744 colon cancer and 335 rectal cancer patients. The number of operations per year increased over time(P=0.037). The median age was 72years(range, 23–98) and this did not change over time(P=0.67). There was also no temporal change in tumor stage distribution(P=0.21) or in the proportion of emergency cases(P=0.75), but the proportion of patients with severe comorbidities increased(P=0.015). The perioperative mortality rate was 4.5%. The median survival after surgery by stage was 123months(Stage I), 141months(Stage II), 76months(Stage III), and 17months(Stage IV tumors). Over the study period, there were improvements in both perioperative mortality(P=0.028) and long-term survival(P=0.0025). Conclusion: Both short-and long-term survivals after surgery for CRC have improved in our institution. Limitation: Although a large regional cohort was analyzed, the study still has its own limitation, in that it is a retrospective single institute study.
  1,336 170 -
Age versus American society of anesthesiologists–Examining 30-day mortality and morbidity in elderly patients undergoing colectomy from the American college of surgeons national surgical quality improvement program
Anne K Mongiu, Rowza T Rumma, Amy K Wise, Russell W Farmer
April-June 2019, 8(2):47-53
Background: As the percentage of the population that is elderly increases, colorectal operations performed in this age group are becoming more common. This study examined the use of the American Society of Anesthesiologists(ASA) Classification System(class) as a predictor of 30-day morbidity and mortality in patients≥90years old. Objective: The objective of this study was to evaluate the use of ASA classification in elderly patients undergoing colorectal surgery to determine whether it is an accurate predictor of perioperative risk. Design and Setting: This was a retrospective database review. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all colectomies, coloproctectomies, and proctectomies performed from 2005 to 2009. Demographic and perioperative information including class and 30-day outcomes were assessed. Amultiple logistic regression model was used to calculate the odds of 30-day morbidity and mortality correlated with age, class procedure type (open vs. minimally invasive), and do not resuscitate (DNR)status. Main Outcome Measures: 30-day mortality and 30-day morbidity. Sample Size: The sample size included 73,974patients. Results: Atotal of 73,974patients were identified including 1276patients≥90years old. Across all patients, multiple logistic regression demonstrated higher odds of 30-day mortality with increase in class(P < 0.001, odds ratio[OR] 5.62), age(P < 0.001, OR 1.04), DNR status(P < 0.001, OR 3.01), and open procedures(P < 0.001, OR 2.60). Subgroup analysis of patients with class≤3 showed increase in 30-day mortality with increased age(P < 0.001, OR 1.05), class(P < 0.001, OR 3.87), DNR status(P < 0.001, OR 5.05), and open procedures(P < 0.001, OR 2.39). For patients ≥90 with class≤3, class was no longer correlated with 30-day mortality(P = 0.251) or morbidity(P = 0.236). Conclusions: In colorectal surgery patients, class is a validated predictor of morbidity and mortality. For the most elderly patients, class indicative of preoperative status of less than a constant threat to life(≤3) increasing class does not correlate with increased morbidity or mortality. Ongoing work is needed to define predictors of risk in these patients. Limitations: This is a retrospective study derived on data retrieved from a national database; we are limited to the preselected variables collected and the potential for missed or omitted patients.
  1,356 142 -
The need for routine colonoscopy after acute diverticulitis revisited
Michelle L Cooper, Cu Tai Lu, Harald Puhalla, Hajir Nabi, Michael Von Papen
January-March 2020, 9(1):1-6
Background: The utility of routine outpatient colonoscopy after the conservative management of complicated and uncomplicated colonic diverticulitis has become questionable. Recent literature suggests this time-honored practice after uncomplicated diverticulitis is to be of little benefit, although uncertainty still persists regarding complicated diverticulitis. Objective: We analysed the rates of benign and malignant pathology identified on colonoscopy after conservatively managed uncomplicated and complicated diverticulitis in a hospital where such colonoscopies have been routine practice. Design: A retrospective cohort study was conducted. Setting: Gold Coast Hospital, Southport, Queensland, Australia. Patients and Methods: All patients who were admitted to the Gold Coast Hospital, Southport, Queensland, Australia, between June 2007 and June 2010 diagnosed with acute uncomplicated and complicated diverticulitis were included in the study. The patients were followed up and colonoscopy reports and histology results obtained. Main Outcome Measures: Benign and malignant pathology post uncomplicated and complicated diverticulitis. Sample Size: 144 patients were eligible for inclusion. Results: Between June 2007 and June 2010, 1073 patients were hospitalized with an admission diagnosis coding for diverticulitis. Of these, 144 patients had a computed tomography (CT) which confirmed the diagnosis of acute diverticulitis. Complete colonoscopy and histology data were obtained for 107 of these patients. Of these, 32 patients (29.91%) had pathology found at colonoscopy. One patient (0.9%) was found to have adenocarcinoma of the colon. Conclusion: Colonoscopy follow-up for acute diverticulitis has remained acceptable in many units to exclude alternate colonic pathology. However, recent literature has questioned the utility of this practice. This study – in keeping with this growing body of international literature – found the rate of synchronous/alternative pathology to be comparable to that of asymptomatic patient populations. Routine colonoscopies after uncomplicated colonic diverticulitis confidently diagnosed with a CT scan, therefore, cannot be justified. Limitations: Retrospective nature and sample size. Conflict of Interest: None.
  1,303 175 1
Abdominosacral resection versus abdominoperineal resection in patients with low rectal carcinoma in terms of exposure/operating time/bleeding
Rishin Dutta, Sujitesh Saha, Makhan Lal Saha, Abhimanyu Basu, Soumen Das, Dipankar Saha
October-December 2019, 8(4):89-97
Background: Comprising nearly 30% of all colorectal cancers, rectal cancer continues to be a significant medical and social problem. Abdominiperineal resection (APR) remains the procedure of choice for patients with rectal carcinoma. An alternative to APR is abdominosacral resection (ASR). Objective: We aim to assess the various modes of presentation, demographic profiles, and histopathological characteristics of tumors, and evaluate the efficacy of ASR over APR in terms of exposure, operating time, bleeding, etc., especially in the perineal/sacral part of the procedure. Design: This was a prospective observational study.Setting: This study was conducted at a superspeciality government hospital in eastern India. Patients and Methods: Patients diagnosed with low rectal carcinoma were included in the study. Two groups were formed using a stratified model of sampling theory; one group underwent APR while the other ASR. Main Outcome Measures: For patients with low rectal cancer, ASR is a feasible approach with reduced bleeding, lesser operating time in the perineal/sacral part of dissection, better exposure, and good oncological outcome.Sample Size: Thirty participants were included in the study. Results: Of the total study participants, 63% were males and 36% females. Patients in their 30s and 40s were the most commonly affected age group. Per-rectal bleeding was the most common presentation. The most common histological tumor encountered was well-differentiated adenocarcinoma. The mean operating time and mean blood loss with regards to the perineal/sacral part of the dissection was less in ASR than that in APR. In addition, the exposure was better in ASR. Ninety-three percent of the patients undergoing ASR had total mesorectal excision. Conclusion: ASR is a feasible approach for low rectal carcinoma and performs better in certain aspects than APR. Limitations: This study had a short duration and included less number of patients. Conflict of Interest: None.
  1,250 159 -
Is routine pathological analysis of perianal fistula specimen necessary in diagnosis of crohn's disease?
Steve Y. C Lau, Casey C. H Yu, Suat C Ng, Raaj Chandra
January-March 2020, 9(1):7-9
Background: Crohn's disease causes recurrent and complex perianal fistulas. Although the prevalence of it is up to 30%, the common cause of perianal fistula is thought to be the crypto-glandular theory. Surgeons send perianal fistula specimens for histopathological analysis; however, it is unclear whether such practices should be performed routinely. Objective: Evaluating the utility of routine histopathology on perianal fistula specimens during surgery to exclude the diagnosis of Crohn's disease. Design: Multicenter retrospective study was conducted from January 2012 to October 2018 on patients who underwent surgery for perianal fistula and specimen sent for histology. Setting: Metropolitan tertiary referral center in Melbourne, Australia. Patients and Methods: 105 patients who underwent 124 anal fistula procedures and their perianal fistula specimens sent for histopathological analysis were selected from the medical database. Medical and pathology reports were analyzed and data were reviewed by a second author for consistency. Sample Size: 105 patients, 124 procedures. Main Outcome Measures: Histopathological results suspicious for Crohn's disease and endoscopic examination results to confirm Crohn's disease. Results: 41 together, 124 perianal fistula specimens were collected from 105 patients. The male to female ratio was 2.9:1 and the average age was 43.6 years. Nonspecific inflammation was seen in 121 (97.5%) specimens. Three specimens had granulomatous inflammation of which, only two (1.6%) had Crohn's disease confirmed on endoscopic biopsy of the terminal ileum. In 15 patients with Crohn's disease, none of the 19 specimens sent for histology demonstrated histopathological features of Crohn's disease. Conclusion: Routine histopathological analyses of perianal fistula specimens provide limited clinical value. Clinicians should selectively send specimens for histopathological analysis to limit the use of resources. Limitations: Retrospective study. Not all perianal fistula specimens were routinely sent for the analysis. Data prior to 2012 was not collected as we are limited by an electronic database which was commenced in 2012. Conflict of Interest: None.
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Right hemicolectomy in a patient with heterotaxy syndrome
Maxime Dewulf, Roel Beckers, Pieter Pletinckx
January-March 2019, 8(1):30-33
In this communication, we present a first description of right hemicolectomy in a patient with heterotaxy syndrome (HS). A 78-year-old male was admitted to the outpatient clinic with complaints of dysphagia. Diagnostic workup revealed the presence of an esophageal web. On subsequent colonoscopy, a tumoral lesion was found in the ascending colon. Computed tomography scan illustrated abdominal situs ambiguous with right-sided polysplenia, right-sided stomach, and intestinal nonrotation. Furthermore, a preduodenal portal vein, azygos continuation of the inferior vena cava, and hemiazygos continuation of the left renal vein were observed. After careful assessment of the anatomy, a right hemicolectomy with radical lymphadenectomy was performed. HS consists of a rare and complex situs anomaly, with an abnormal arrangement of the thoracic and/or abdominal organs along the left–right axis. To our knowledge, right hemicolectomy has not been described in patients with HS.
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Current status of robotic colorectal surgery in Australasia: Aquestionnaire survey of consultant members of the colorectal surgical society of Australia and NewZealand
Kenneth N Buxey, Francis F Lam, Graham L Newstead
April-June 2019, 8(2):44-46
Background: There has been considerable interest worldwide in the application of a robotic operating platform in the practice of colorectal surgery. Objective: The aim of this study was to evaluate the current uptake of robotic colorectal surgery in Australia and NewZealand. Design: Survey data were obtained from the Colorectal Surgical Society of Australia and NewZealand(CSSANZ) registry of all specialist colorectal surgeons in Australia and NewZealand. Setting: Specialist colorectal surgeons responded to the survey through e-mail contact via an official e-mail from the CSSANZ. Materials and Methods: A questionnaire was distributed to members of the CSSANZ regarding their current robotic surgical practice. Main Outcome Measures: Volume of and nature of robotic surgery being currently undertaken in Australia and NewZealand, with an emphasis on seeking to understand the surgeon and patient factors that would promote robotic practice and also any factors or barriers in the implementation of robotic colorectal surgery being performed. Sample Size: The sample size was 77. Results: Seventy-seven replies were received from a total of 227 surveys. The response rate is similar to other comparable surveys published when the laparoscopic colorectal era was introduced. Most surgeons performed minimally invasive(laparoscopic) surgery; however, only 29% performed any robotic surgery and 50% of these performed<5cases in the preceding 12months. Low rectal cancer and rectopexy surgeries were the most frequently performed robotic operations. About 48% of surgeons believed that the robotic platform offers specific patient benefits, and 75% believed that it offers specific benefits to the surgeon. The main reason for consultants not performing robotic procedures was largely related to cost, with training also cited as a barrier. Conclusion: Robotic colorectal surgery is being performed by 29% of colorectal consultants in Australasia, although only a minority of these surgeons have a substantial volume. In the future, a substantial reduction in costs is envisaged, as more companies enter the robotic surgery marketplace and competition drives reduction in costs. This in many ways mirrors the introduction of laparoscopy and we believe as cost comes down, training pathways need to be established to train the next generation of colorectal surgeons robotically. Limitations: Our study is limited by inherent limitations of survey data and the response rate.
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CYP2C9 polymorphism is not associated with elevated carcinoembryonic antigen levels
Claire Hall, Rebecca Roberts, Tony R Merriman, Atanu Pal, Tim Eglinton, Chris Wakeman, Frank Frizelle
April-June 2019, 8(2):54-57
Background: Carcinoembryonic antigen (CEA) is a glycoprotein that can be elevated in a number of benign and malignant conditions. In colorectal cancer, it is used as a prognostic marker and to detect recurrence. However, it lacks specificity and may become elevated in individuals without a history of cancer or other identifiable cause leading to costly and invasive investigation. Objective: The aim of this study was to assess whether genetic polymorphisms in the liver enzyme CYP2C9 could explain high CEA levels in otherwise normal individuals. Design: This is a case-control study. Setting: Individuals were genotyped for the poor metabolizer (PM) alleles CYP2C9*2 and CYP2C9*3 using predesigned TaqMan single nucleotide polymorphisms assays. Patients and Methods: Nineteen individuals with previously clinically unexplained elevated CEA and 567 healthy Caucasian controls were included. Main Outcome Measures: Chi-square analysis was used to test for association of CYP2C9 genotype with plasma CEA concentration. Sample Size: Nineteen individuals with previously clinically unexplained elevated CEA and 567 healthy Caucasian controls were included. Results: Fifteen of the 19 individuals with previously high CEA had elevated plasma CEA (>3.0μg/L) on re-testing. The frequency of CYP2C9 PM alleles in these 15 patients was not significantly higher than the frequency in controls. Conclusion: CEA concentrations do not appear to be influenced by CYP2C9 genotype, so this cannot be used to explain elevated CEA in the absence of an obvious clinical cause. Limitation: Small sample size.
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Mixed adenoneuroendocrine tumor of the perianal skin
Daniel J Mullins, Robert T Lewis
April-June 2019, 8(2):61-63
Mixed adenoneuroendocrine carcinoma (MANEC) of the intestinal tract, is relatively rare and with a poor prognosis. The majority of literature to date has documented the rare occurrence of this tumor within the colon or rectum, but not within the anal canal or verge. We report our case of a female patient identified with a MANEC tumor of the perianal skin extending into the anal canal.
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