Radiological evaluation of colorectal anastomoses

Background and aims: The purpose of this study was to determine the accuracy, interobserver variability, timing and discordance with relaparotomy of postoperative radiological examination of colorectal anastomoses. Patient/methods: From 2000 to 2005, 429 patients underwent an

Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial)

BACKGROUND: Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs. Both focus on a faster recovery and shorter hospital stay. The randomized controlled multicenter LAFA-trial (LAparoscopy and/or FAst track multimodal management versus standard care) was conceived to determine whether laparoscopic surgery, fast track perioperative care or a combination of both is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease. METHODS/DESIGN: The LAFA-trial is a double blinded, multicenter trial with a 2 × 2 balanced factorial design. Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be randomized to either open or laparoscopic colectomy, and to either standard care or the fast track program. This factorial design produces four treatment groups; open colectomy with standard care (a), open colectomy with fast track program (b), laparoscopic colectomy with standard care (c), and laparoscopic surgery with fast track program (d). Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days. Secondary outcome parameters are quality of life two and four weeks after surgery, overall hospital costs, morbidity, patient satisfaction and readmission rate. Based on a mean postoperative hospital stay of 9 +/- 2.5 days a group size of 400 patients (100 each arm) can reliably detect a minimum difference of 1 day between the four arms (alfa = 0.95, beta = 0.8). With 100 patients in each arm a difference of 10% in subscales of the Short Form 36 (SF-36) questionnaire and social functioning can be detected. DISCUSSION: The LAFA-trial is a randomized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

Purpose: Pelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence. Materials and methods: Two hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score. Results: After pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD±3) was reduced with 3.2 points (p<0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R2, 0.18). Th

Anal fistulotomy between Skylla and Charybdis

OBJECTIVE: This study was undertaken to assess the results of anal fistulotomy on faecal continence, recurrence and satisfaction. METHODS: We reviewed the records of 60 patients who underwent anal fistulotomy between 1997 and 2000. Follow-up was by a questionnaire with 46 (77%) patients responding. Mean follow-up was 1-4 years. Fistulas were intersphincteric in 12 patients and transsphincteric in 34 patients. Operative procedure consisted of fistulotomy. RESULTS: Of 11 patients with high fistula, 9 (82%) had impaired continence; Of 17 patients with midanal fistula, 4 (24%) suffered impaired continence. Eighteen patients had a low fistula and 8 (44%) developed impaired continence. In the whole group 50% had suffered faecal incontinence. There were no recurrences and there was satisfaction with the situation in 87% of patients. CONCLUSIONS: Fistulotomy for primary fistula in ano in this retrospective study with a follow-up up to 4 years was associated with no recurrences. Eighty-two percent of patients with a high anal opening have impaired faecal continence, nevertheless patients' satisfaction is hig

Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy

Objective: Anorectal function is greatly disturbed after rectal surgery with or without radiotherapy (RT). To clarify the underlying mechanisms, we designed a prospective study to evaluate the effect of RT and surgery on anorectal function and clinical outcome of patients with a rectal carcinoma. Methods: Thirty-four patients with a rectal carcinoma participated in this study. They filled out a symptom questionnaire and underwent anal manometry, anal and rectal mucosal electrosensitivity testing, and a rectal barostat, before surgery, 4 and 12 months postoperatively. Thirteen patients were lost to follow-up, 14 underwent surgery alone (total mesorectal excision [TME]), and seven also received RT (RT+TME). Results: Functional outcome was disappointing in both groups, with at 4 months a significantly higher defecation frequency after RT+TME as compared with TME. Anal sphincter function and rectal sensitivity to pressure-controlled distention were not affected by either treatment. Rectal compliance, however, was significantly reduced after RT+TME at 4 and 12 months, resulting in lower rectal volumes at the thresholds for first sensation and desire to defecate. Rectal but not anal mucosal electrosensitivity was higher after TME+RT. Conclusions: Anorectal function after rectal surgery with or without RT is greatly hampered because of a decreased rectal compliance. After 12 months, partial improvement is shown, especially in the absence of R

Factors determining delay in relaparotomy for anastomotic leakage after colorectal resection

AIM: To analyze the time interval ('delay') between the first occurrence of clinical parameters associated with anastomotic leakage after colorectal resection and subsequent relaparotomy. METHODS: In 36 out of 289 consecutive patients with colorectal anastomosis, leakage was confirmed at relaparotomy. The medical records of these patients were retrospectively analysed and type and time of appearance of clinical parameters suggestive of anastomotic leakage were recorded. These parameters included heart rate, body temperature, local or generalized peritoneal reaction, leucocytosis, ileus and delayed gastric emptying. Factors influencing delay of relaparotomy and consequences of delayed recognition and treatment were determined. RESULTS: First documentation of at least one of the predefined parameters for anastomotic leakage was after a median interval of 4 +/- 1.7 d after the operation. The median number of days between first parameter(s) associated with leakage and relaparotomy was 3.5 +/- 5.7 d. The time interval between the first signs of leakage and relaparotomy was significantly longer when a weekend was included (4.2 d vs 2.4 d, P = 0.021) or radiological evaluation proved to be false-negative (8.1 d vs 3.5 d, P = 0.007). No significant association between delay and number of additional relaparotomies, hospital stay or mortality could be demonstrated. CONCLUSION: An intervening weekend and negative diagnostic imaging reports may contribute to a delay in diagnosis and relaparotomy for anastomotic leakage. That delay was more than two days in two-thirds of the patient

J-pouch vs side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision for rectal cancer: A multicentre randomized trial

Aim Comparison of functional and surgical outcome of the J-pouch with the side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision in rectal cancer patients. Method In a multicentre study, patients with a carcinoma of the lower two-thirds of the rectum were randomized to either a J-pouch or a side-to-end reconstruction. Primary outcome was function of the neorectum 1year after surgery. A functional outcome [COloREctal Functional Outcome (COREFO)] questionnaire, and two quality of life questionnaires (EORTC-QLQ-CR38 and SF-36) were to be completed by all participants preoperatively, and 4 and 12months postoperatively. Independent data managers recorded surgical outcome. A group size of 30 patients in each group was calculated based on a 15-point difference of the COREFO scale. Results In total, 107 patients were randomized, 55 in the J-pouch group and 52 in the side-to-end anastomosis group. The COREFO incontinence scale at 4months and the total functional outcome at 4 and 12months showed better results for the J-pouch group in comparison with the side-to-end anastomosis group. The remaining COREFO scales (frequency, social impact, stool-related aspects and bowel medication), surgical outcome (complications, reoperations, length of hospital stay, readmissions and mortality) and quality of life did not show significant differences between treatment groups. Conclusion The overall results of a coloanal J-pouch and a side-to-end anastomosis are comparable, although functional results are slightly better with a J-pouch. The side-to-end anastomosis is technically less demanding and therefore a justified alternative in sphincter-saving surgery