Biomedical subjects

A J Senagore

Publications and source records attributed to A J Senagore.

At least 19 recordsLinked to original sources

PubMed2006

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation.

An international working party was convened in Rome, Italy on 16-17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so-called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

Constipation↗

PubMed2005

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study.

BACKGROUND: Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited. METHODS: Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey. RESULTS: A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to 10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17). CONCLUSIONS: The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Abdomen↗

PubMed2005

Laparoscopic vs open total colectomy: a case-matched comparative study.

BACKGROUND: Open total colectomy and ileorectal anastomosis (OTC) is a major colorectal procedure which would preclude laparoscopy in many centers because of technical difficulty and the fact that laparoscopic total colectomy (LTC) takes much longer than standard laparoscopic proctosigmoidectomy (LPS). This study compares OTC with LTC and LPS. METHODS: In this study, 34 LTC patients (May 1999 to August 2003) were matched for age, diagnosis, operative period, and procedure with patients undergoing OTC. Patients with a previous major laparotomy were excluded from the open group. Groups were compared for gender, American Society of Anesthesiology (ASA) classification, operating time, estimated blood loss, length of hospital stay (LOS), complications including readmissions, and costs. The LPS cases were picked randomly from the laparoscopic database (every eighth patient), and the OT and LOS were noted. RESULTS: The LTC and OTC groups were matched for age (mean, 31 vs 34 years; p = 0.2), sex (14 vs 13 females; p = 0.8), ASA (8/23/3/0 vs 8/22/4/0, class 1/2/3/4). The body mass index was higher in the open group (23.8 vs 27.9; p = 0.04). The operating time was significantly longer (187 vs 126 min; p = 0.0001) and the median LOS shorter in the LTC group (3 days [IQR, 2.5-5 days] vs 6 days [IQR 4-8 days]; p = 0.0001). The estimated blood loss was significantly less in the LTC group (168 [50-700] ml) vs 238 [50-800] ml); p = 0.001, but there was no significant difference in the complication (26.5% vs 38.2%; p = 0.4) readmission (11.8% vs 14.7%; p = 1.0), reoperative rates (8.8% vs 11.8%; p = 1.0), or direct costs ($4,578 vs $4,562; p = 0.3). One LTC patient died expired on postoperative day 2 of a cardiac event. Four patients (11.8%) required conversion for obesity (n = 2), adhesions (n = 1), or intraoperative hemorrhage (n = 1). The operating times were 36 min longer in the LTC group than in the LPS group (151 vs 187 min; p = 0.02), but there was no significant difference in the LOS. (3 vs 3 days, p = 0.2). CONCLUSIONS: The findings show that LTC provides a significant decrease in the LOS over OTC, with increased operating time, but without any change in other parameters. A laparoscopic approach to subtotal colectomy is recommended for suitable patients when an experienced team is available.

Adult↗

PubMed2004

Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases.

BACKGROUND: Laparoscopic surgery has been applied to the management of various colorectal conditions, with shorter recovery periods than reported for open surgery. This study reviewed the feasibility and outcome of laparoscopic surgery for benign internal enteric fistulas. METHODS: All the patients undergoing laparoscopic surgery for colovesical, colovaginal, enterovesical, and enterocolic fistulas caused by diverticulitis or Crohn's disease from 1995 to 2003 were identified from the prospective laparoscopic surgery database and retrospectively analyzed. Crohn's ileo-ileal fistulas were excluded from the study because these are generally resected more simply en bloc with the terminal ileum. RESULTS: This study enrolled 43 patients (23 men and 20 women) with median age of 43 years, a mean body mass index of 24.5, and in American Society of Anesthesiology (ASA) distribution of 3/33/8/0 (class 1/2/3/4). The diagnosis was diverticular for 24 patients and Crohn's disease for 19 patients. The mean operative time was 163 +/- 80 min (155 in completed and 180 in converted cases), and the mean length of hospital stay was 5.2 +/- 4.7 days (3.9 in completed and 7.9 days in converted cases). A total of 14 patients (32.6%) required conversion for dense adhesions (n = 8), duodenal involvement (n = 3), multiple fistulae (n = 1), fecal leak (n = 1), and additional pathology (n = 1). Conversion rates, analyzed by fistula type, were duodenal (100%), vaginal (66.7%), sigmoid (27.7%), bladder (15.4%), enterocolic (0%), and colocolic (0%). There were six major complications (14%) including anastomotic leak (n = 3), abscesses (n = 2), and postoperative bleeding (n = 1). There were seven minor complications (16.3%) including postoperative ileus (n = 2), transient pleural effusion (n = 1), wound infection (n = 1), transient small bowel obstruction (n = 2), and brachial plexus neuralgia (n = 1). There was no significant difference in the complication (p = 0.57), reoperation (p = 0.3), or readmission (p = 0.4) rates between the completed and converted cases. CONCLUSIONS: Laparoscopic surgery for benign internal enteric fistula offers the earlier recovery seen with other laparoscopic colorectal operations. Duodenal and vaginal involvement by the fistula is associated with a higher conversion rate. A low threshold toward early conversion is useful in these difficult cases to reduce delays in the operating room and the unnecessary use of hospital resources.

Adult↗

PubMed2004

Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients.

BACKGROUND: This study aimed all develop a mathematical model for predicting the conversion rate for patients undergoing laparoscopic colorectal surgery. METHOD: This descriptive single-center study used routinely collected clinical data from 1,253 patients undergoing laparoscopic surgery between November 1991 and April 2003. A two-level hierarchical regression model was used to identify patient, surgeon, and procedure-related factors associated with conversion of laparoscopic to open surgery. The model was internally validated and tested using measures of discrimination and calibration. Exclusion criteria for laparoscopic colectomy included a body mass greater than 50, lesion diameter exceeding 15 cm, and multiple prior major laparotomies (exclusive of appendectomy, hysterectomy, and cholecystectomy). RESULTS: The average conversion rate for the study population was 10.0% (95% confidence interval [CI], 8.3-11.7%). The independent predictors of conversion of laparoscopic to open surgery were the body mass index (odds ratio [OR], 2.1 per 10 Americans Society of Anesthesiology units increase), (ASA) grade 3 or 4, 1 or 2 (OR, 3.2, 5.8), type of resection (low rectal, left colorectal, right colonic vs small/other bowel procedures; OR, 8.82, 4.76, 2.98), presence of intraoperative abscess (OR, 3.60) or fistula (OR, 4.73), and surgeon seniority (junior vs senior staff OR, 1.56). The model offered adequate discrimination (area under receiver operator characteristic curve, 0.74) and excellent agreement (p = 0.384) between observed and model-predicted conversion rates (range of calibration, 3-32% conversion rate). CONCLUSIONS: Laparoscopic conversion rates are dependent on a multitude of factors that require appropriate adjustment for case mix before comparisons are made between or within centers. The Cleveland Clinic Foundation (CCF) laparoscopic conversion rate model is a simple additive score that can be used in everyday practice to evaluate outcomes for laparoscopic colorectal surgery.

Adolescent↗

PubMed2004

Analysis of the outcome of ileal pouch-anal anastomosis in patients with Crohn's disease.

PURPOSE: Ileal pouch-anal anastomosis has come to represent the procedure of choice for patients requiring surgery for mucosal ulcerative colitis. In contrast, a proven diagnosis of Crohn's disease is generally held to preclude ileal pouch-anal anastomosis. However, patients with ileal pouch-anal anastomosis for apparent mucosal ulcerative colitis who are subsequently found to have Crohn's disease have a variable course. We reviewed our experience in this scenario to determine whether selected patients with Crohn's disease may be candidates for ileal pouch-anal anastomosis. METHODS: A retrospective review of the prospectively maintained ileal pouch-anal anastomosis database was undertaken to identify patients with a diagnosis of Crohn's disease after ileal pouch-anal anastomosis. Clinical outcome and quality-of-life data were obtained from the database and chart review. End points were the development of recrudescent Crohn's disease, pouch failure, and quality of life and functional outcome at the time of data collection. Differences between groups were calculated using the chi-squared test. Cumulative incidence of recrudescent Crohn's disease and pouch loss were calculated by the Kaplan-Meier method. Factors predictive of development of recrudescent Crohn's disease and pouch loss were examined by univariate analysis. RESULTS: Sixty patients (32 females; median age, 33 (range, 15-74) years) who underwent ileal pouch-anal anastomosis for mucosal ulcerative colitis subsequently had that diagnosis revised to Crohn's disease. Median follow-up of all patients was 46 (range, 4-158) months at time of data collection by which time 21 patients (35 percent) had developed recrudescent Crohn's disease. No pre-ileal pouch-anal anastomosis factors examined were predictors of the development of recrudescent Crohn's disease on univariate analysis. Median follow-up of the latter group was 63 (range, 0-132) months from time of diagnosis, by which time six patients underwent pouch excision and another patient was permanently defunctioned. The overall pouch loss rate for the entire cohort was 12 percent and 33 percent for those with recrudescent Crohn's disease. Median daily bowel movements in those with ileal pouch-anal anastomosis in situ at the time of data collection was 7 (range, 3-20), with 50 percent of patients rarely or never experiencing urgency and 59 percent reporting perfect or near perfect continence. Median quality of life, health, and happiness scores were 9.9 and 10 of 10. CONCLUSIONS: The secondary diagnosis of Crohn's disease after ileal pouch-anal anastomosis is associated with protracted freedom from clinically evident Crohn's disease, low pouch loss rate, and good functional outcome. Such results only can be improved by the continued development of medical strategies for the long-term suppression of Crohn's disease. These data support a prospective evaluation of ileal pouch-anal anastomosis in selected patients with Crohn's disease.

Adolescent↗

PubMed2004

A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results.

PURPOSE: There is a growing body of evidence supporting the lesser degrees of pain with stapled hemorrhoidopexy, also called the procedure for prolapse and hemorrhoids. However, there have been few randomized comparisons assessing both perioperative and long-term outcomes of the procedure for prolapse and hemorrhoids and Ferguson hemorrhoidectomy. Results are presented here from the first prospective, randomized, multicenter trial comparing these hemorrhoid procedures in the United States. METHODS: Patients with prolapsing hemorrhoids (Grade III) were randomized to undergo the procedure for prolapse and hemorrhoids or Ferguson hemorrhoidectomy by colorectal surgeons who had training in using the stapling technique. Primary end points were acute postoperative pain, and hemorrhoid symptom recurrence requiring additional treatment at one-year follow-up from surgery. RESULTS: A total of 156 patients (procedure for prolapse and hemorrhoids, 77; Ferguson, 79) completed randomization and the surgical procedure, 18 (procedure for prolapse and hemorrhoids, 12; Ferguson, 6) had significant protocol violations. One hundred seventeen patients (procedure for prolapse and hemorrhoids, 59; Ferguson, 58) returned for one-year follow-up. Demographic parameters, hemorrhoid symptoms, preoperative pain scores, and bowel habits were similar between groups. There were a similar number of patients with adverse events in each group (procedure for prolapse and hemorrhoids, 28 (36.4 percent) vs. Ferguson, 38 (48.1 percent); P = 0.138). Reoperation for an adverse effect was required in six (7.6 percent) Ferguson patients and in 0 patients having the procedure for prolapse and hemorrhoids (P = 0.028). Postoperative pain during the first 14 days, pain at first bowel movement, and need for postoperative analgesics were significantly less in the procedure for prolapse and hemorrhoids group. Control of hemorrhoid symptoms was similar between groups; however, significantly fewer patients having the procedure for prolapse and hemorrhoids required additional anorectal procedures during one-year follow-up (procedure for prolapse and hemorrhoids, 2 (2.6 percent), vs. Ferguson, 11 (13.9 percent); P = 0.01). Only four of the Ferguson patients (5 interventions) required additional procedures more than 30 days after surgery. CONCLUSIONS: These data demonstrate that stapled hemorrhoidopexy offers the benefits of less postoperative pain, less requirement for analgesics, and less pain at first bowel movement, while providing similar control of symptoms and need for additional hemorrhoid treatment at one-year follow-up from surgery.

Analysis of Variance↗

PubMed2004

Shorter hospital stay associated with fastrack postoperative care pathways and laparoscopic intestinal resection are not associated with increased physical activity.

OBJECTIVE: Recent prospective studies have shown that 'fast track' postoperative care protocols (FT) can reduce hospitalization after major intestinal surgery to 4.5 days, as compared to the 7-10 days with traditional management (TR) and 2.5 days after laparoscopic surgery (LC). We used computerized actigraphy (CA) to evaluate physical activity using TR, FT and LC approaches. METHODS: Fifteen patients undergoing intestinal resection by LC, TR and FT were recruited. CA devices were placed on the wrist and ankle of each patient from day 1 until hospital discharge. Intra-patient and intergroup analyses were performed using 24 h evaluations, and periods from 0800-2000 h. Results are presented for, level of activity (LOA; activity counts per minute), activity index (AI;% epochs with activity) and acceleration index (ACI; change in activity rate during analysis period) for 0800-2000 h. RESULTS: Levels of activity measured by wrist and ankle CA devices for the three different care protocols were: LC, 6263 +/- 8008 (wrist), 1640 +/- 3795 (ankle); FT 7874 +/- 8550 (wrist), 2153 +/- 4838 (ankle); LC 8526 +/- 9917 (wrist), 2326 +/- 4905 (ankle). Length of hospital stay was significantly shorter in LC than FT and TR patients (P < 0.01). There was no significant increase in wrist or ankle LOA for FT or LC patients. Similarly, there was no difference in AI or ACI. CONCLUSION: Although CA is an easily standardized method of evaluating physical activity after major abdominal surgery, no difference can be demonstrated between activity levels in patients managed by differing care pathways. Reductions in stay may be associated with factors other than a change in the level of physical activity after surgery.

Adult↗

PubMed2003

Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy.

BACKGROUND: This randomized clinical trial compared the use of thoracic epidural anaesthesia-analgesia (TEA) with morphine patient-controlled analgesia (PCA) for pain relief after laparoscopic colectomy. METHODS: Patients scheduled for segmental laparoscopic colectomy were randomized to receive TEA or PCA. Patients in the TEA group received bupivacaine and fentanyl before incision and after surgery by continuous infusion for 18 h. Patients in the PCA group self-administered morphine using an intravenous pump. The postoperative care plan was otherwise identical for the two groups. Postoperative pain was measured during ambulation using a visual analogue pain score. RESULTS: The study included 38 patients (18 TEA, 20 PCA), 16 of whom underwent right hemicolectomy or ileocolectomy and 22 sigmoid colectomy. Operating times, patient weight and distribution of American Society of Anesthesiologists grade were similar in the two groups. The mean(s.e.m.) total dose of drugs administered was 64(41) mg morphine in the PCA group, and 79(42) mg bupivacaine and 205(140) micro g fentanyl in the TEA group. Postoperative pain scores were significantly better in the TEA group at 6 h (mean(s.e.m.) 2.2(0.4) versus 6.6(0.5) with PCA; P = 0.001) and 18 h (2.2(0.3) versus 4.0(0.4); P = 0.003). Hospital stay was similar in the two groups. CONCLUSION: TEA significantly improved early analgesia following laparoscopic colectomy but did not affect the length of hospital stay.

Analgesia, Patient-Controlled↗

PubMed2003

Evaluation of POSSUM and P-POSSUM scoring systems in assessing outcome after laparoscopic colectomy.

BACKGROUND: The purpose of this study was to compare the actual and predicted risk-adjusted morbidity and mortality after laparoscopic colectomy (LAC) calculated using both the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) scoring systems. METHODS: All patients who underwent LAC performed by a single surgeon between March 1999 and December 2000 were analysed. The observed morbidity and mortality rates were compared with those predicted by the POSSUM scoring system, and the observed mortality rate with that predicted by P-POSSUM. The operative severity component of the operative score was sequentially decreased from 4 (standard score for open colectomy) to 2, then 1, in an attempt to correct overprediction. RESULTS: Two hundred and fifty-one consecutive patients underwent LAC, with a conversion rate of 8.0 per cent. The morbidity rate (6.8 per cent) was significantly lower than the predicted rates calculated with an operative score of 4 or 2 (12.4 per cent, P < 0.001; 9.6 per cent, P = 0.001), but was fully corrected with an operative score of 1 (7.0 per cent, P = 0.325). The observed mortality rate (0.8 per cent) was significantly different from the expected mortality rates calculated using either uncorrected POSSUM (9.6 per cent, P = 0.001) or P-POSSUM (3.5 per cent, P = 0.001). POSSUM (2.6 per cent, P = 0.007) continued to overpredict mortality but P-POSSUM (1.0 per cent, P = 0.001) accurately predicted mortality with an operative score of 1. CONCLUSION: LAC appeared to be associated with lower morbidity and mortality rates than those predicted by the POSSUM scoring system, and with a lower mortality rate than that predicted using the P-POSSUM system.

Adolescent↗

PubMed2002

Clinically based management of rectal prolapse.

BACKGROUND: Laparoscopic repair of rectal prolapse offers the potential of lower recurrence rates for transabdominal repair coupled with the advantages of minimally invasive colorectal surgery. There have been no direct comparisons of the laparoscopic Wells procedure (LWP) and laparoscopic resection with rectopexy (LRR). This study is the first to make a direct comparison of outcomes from laparoscopic LRR and LWP repairs using a selected, symptom-based choice of operative procedure. METHODS: Consecutive patients presenting with complete rectal prolapse were evaluated by clinical history of the degree of constipation, diarrhea, or incontinence. Patients with a history of constipation or normal bowel habits with normal continence underwent LRR, whereas those with diarrhea or anal incontinence underwent LWP. The collected data included age, gender, operative time, length of hospital stay (LOS), operative blood loss, complications, and postoperative symptoms of constipation or diarrhea. Continence was scored using the Cleveland Clinic scoring system. RESULTS: Of the 24 patients, 11 underwent LRR and 13 had LWP. The patients in both groups were predominantly, female (LRR, 9/1; LWP, 10/2). The LRR patients were significantly younger (48.6 vs 63.9 years p <0.001). Both operative time and LOS were significantly longer in the RR group (operative time, 128.5 +/- 80.6 min vs 69.9 +/- 13.4 min; LOS, 3.6 +/- 3.1 days vs 2.2 +/- 1.03 days). All patients in the LRR group had constipation preoperative, and no patients were incontinent clinically. Preoperatively, 7 of the 13 patients in the LWP group had preoperative diarrhea, and 1 patient had clinical constipation. A five patients experienced clinical symptoms of fecal incontinence, manifested in different degrees. Postoperative complications occurred only in the LRR group (1 case of abdominal wall hematoma and 2 cases of prolonged ileus). During a mean follow-up period of 18.1 months, there were no recurrences; 10 of the 11 LRR patients had correction of constipation; and 4 of 5 of the incontinent LWP patients had improvement in their symptoms. Constipation developed in one LWP patient. CONCLUSIONS: Clinical assessment of preoperative bowel function and continence allows accurate selection of the appropriate laparoscopic technique for repair of rectal prolapse without the added expense of anal physiologic testing. Although LRR may be associated greater morbidity than LWP, both procedures offer good functional outcome, with short LOS and low recurrence rates.

Adult↗

PubMed2002

Factors affecting local recurrence of colonic adenocarcinoma.

PURPOSE: The aim of this retrospective study was to determine which aspects of tumor morphology and histology influenced the incidence of local recurrence after curative resection of colonic adenocarcinoma. METHODS: Patients who had a curative resection for a primary colonic adenocarcinoma between 1980 and 1993 (inclusive) were identified from the colorectal cancer database in the Department of Colorectal Surgery. The charts of patients diagnosed with a local recurrence were then reviewed and their findings at operation and histologic assessment analyzed. Patients were followed up for at least five years or until death. RESULTS: Over the period of study, 1,031 patients had a curative resection for colonic adenocarcinoma. Local recurrences were detected in 32 patients (3.1 percent). The gender distribution of patients with local recurrence was 18 males (56.3 percent) and 14 females (43.7 percent) with a mean age of 63.4 years. The median time to local recurrence was 13 (range, 2-71) months. The distribution of primary tumors that recurred locally favored the cecum (n = 9; 28.1 percent) and sigmoid colon (n = 14; 43.7 percent) over other locations; these were, however, the most common sites of primary lesions. Less common sites included the ascending colon (n = 0; 0 percent), hepatic flexure (n = 2; 6.3 percent), transverse colon (n = 1; 3.1 percent), splenic flexure (n = 3; 9.4 percent), and descending colon (n = 3; 9.4 percent). Of the total number of tumors, 101 were found to be adherent to at least 1 other intra-abdominal viscus, and 12 (11.9 percent) recurred locally. Other factors associated with local recurrence were tumor perforation and fistulation. Overall, 30 tumors (2.9 percent) were perforated, and 6 (20 percent) recurred locally. Four tumors (0.4 percent) were fistulating; of these, 2 (50 percent) recurred locally. Advanced tumor stage was also associated with an increased rate of local recurrence (Stage I, 0 percent; Stage II, 2.05 percent; Stage III, 7.0 percent; and Stage IV, 6.1 percent). Similarly, tumor differentiation was related to local recurrence, with no instances in well-differentiated tumors, 2.8 percent in moderately differentiated tumors, and 6.8 percent in poorly differentiated tumors. CONCLUSIONS: The location of the primary tumor is not a factor in producing local recurrence. Fixity to another viscus, perforation or fistulation, advanced stage of disease, and differentiation of tumor appear to increase the chances of recurrence of curatively resected colonic carcinoma. Although the recurrence rate is higher in these groups than for tumors overall, definitive oncologic surgery prevents recurrence in the majority of cases. No colonic tumor that was T1 or T2 (N0, N1, or N2) or that was well differentiated recurred locally.

Adenocarcinoma↗

PubMed2002

Pan-colonic decrease in interstitial cells of Cajal in patients with slow transit constipation.

BACKGROUND: Interstitial cells of Cajal (ICC) are required for normal intestinal motility. ICC are found throughout the human colon and are decreased in the sigmoid colon of patients with slow transit constipation. AIMS: The aims of this study were to determine the normal distribution of ICC within the human colon and to determine if ICC are decreased throughout the colon in slow transit constipation. PATIENTS: The caecum, ascending, transverse, and sigmoid colons from six patients with slow transit constipation and colonic tissue from patients with resected colon cancer were used for this study. METHODS: ICC cells were identified with a polyclonal antibody to c-Kit, serial 0.5 microm sections were obtained by confocal microscopy, and three dimensional software was employed to reconstruct the entire thickness of the colonic muscularis propria and submucosa. RESULTS: ICC were located within both the longitudinal and circular muscle layers. Two networks of ICC were identified, one in the myenteric plexus region and another, less defined network, in the submucosal border. Caecum, ascending colon, transverse colon, and sigmoid colon displayed similar ICC volumes. ICC volume was significantly lower in the slow transit constipation patients across all colonic regions. CONCLUSIONS: The data suggest that ICC distribution is relatively uniform throughout the human colon and that decreased ICC volume is pan-colonic in idiopathic slow transit constipation.

Adolescent↗

PubMed2001

Kirsten ras mutations in patients with colorectal cancer: the 'RASCAL II' study.

Researchers worldwide with information about the Kirsten ras (Ki-ras) tumour genotype and outcome of patients with colorectal cancer were invited to provide that data in a schematized format for inclusion in a collaborative database called RASCAL (The Kirsten ras in-colorectal-cancer collaborative group). Our results from 2721 such patients have been presented previously and for the first time in any common cancer, showed conclusively that different gene mutations have different impacts on outcome, even when the mutations occur at the same site on the genome. To explore the effect of Ki-ras mutations at different stages of colorectal cancer, more patients were recruited to the database, which was reanalysed when information on 4268 patients from 42 centres in 21 countries had been entered. After predetermined exclusion criteria were applied, data on 3439 patients were entered into a multivariate analysis. This found that of the 12 possible mutations on codons 12 and 13 of Kirsten ras, only one mutation on codon 12, glycine to valine, found in 8.6% of all patients, had a statistically significant impact on failure-free survival (P = 0.004, HR 1.3) and overall survival (P = 0.008, HR 1.29). This mutation appeared to have a greater impact on outcome in Dukes' C cancers (failure-free survival, P = 0.008, HR 1.5; overall survival P = 0.02, HR 1.45) than in Dukes' B tumours (failure-free survival, P = 0.46, HR 1.12; overall survival P = 0.36, HR 1.15). Ki-ras mutations may occur early in the development of pre-cancerous adenomas in the colon and rectum. However, this collaborative study suggests that not only is the presence of a codon 12 glycine to valine mutation important for cancer progression but also that it may predispose to more aggressive biological behaviour in patients with advanced colorectal cancer.

Adolescent↗

PubMed2001

The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices.

BACKGROUND: Colonic endolumenal stenting (CELS) to treat obstructing colorectal neoplasms was first described in 1991. The aim of this study was to review the published world literature and make recommendations for its use in current clinical practice. METHODS: Suitable English language reports were identified using a Medline search. RESULTS: CELS can been successfully accomplished in 64% to 100% of obstructing malignant colonic lesions. Distal lesions are more common and theoretically more easy to stent although lesions within the ascending colon have been successfully managed. Minor complications include transient anorectal pain and rectal bleeding, however, significant complications of stent dislocation and colonic perforation are also well recognized. CONCLUSION: CELS can aid the palliative management of malignant colorectal obstruction. Its role in relieving obstruction prior to resection remains to be defined. Increasing experience has allowed the safe placement of stents and relief of obstruction of virtually any lesion throughout the large bowel.

Colorectal Neoplasms↗

PubMed2001

'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery.

BACKGROUND: A combination of factors has emphasized the need to reduce postoperative stay after surgery. Multimodal care plans may shorten hospital stay, but have been associated with high readmission rates and are generally reserved for straightforward, non-complicated colonic (not rectal) resections. This study evaluated a 'fast track' protocol in patients undergoing major colonic and rectal surgery. METHODS: Sixty consecutive patients (median age 44.5 (range 13-70) years) underwent major procedures over a 6-week period on one colorectal service. Nasogastric tubes and epidural anaesthesia were not used. Patients participated in a protocol of early diet and early ambulation, and were discharged after meeting defined criteria. RESULTS: Fifty-eight patients (97 per cent) were deemed suitable for the 'fast track' approach at the time of surgery and stayed for a mean(s.d.) of 4.3(1.6) days after operation. Patients in diagnosis-related group (DRG) 148 (colorectal resection with co-morbidity; n = 40) stayed for 4.6(1.7) days, which was longer than those in DRG 149 (without co-morbidity; n = 18) who stayed 3.5(0.8) days (P = 0.01). Three patients (5 per cent) required a nasogastric tube for vomiting. There were no readmissions directly attributable to 'fast track' failure, although four patients (7 per cent) were readmitted within 30 days of operation for other reasons. Eight poorly compliant patients stayed for 5.1(1.1) days (P = 0.02 versus compliant patients). 'Fast track' patients had a shorter length of stay than patients receiving traditional care on other colorectal services during the same time period (compared by DRG 148, DRG 149 and for all patients) (P < 0.0001). CONCLUSION: The 'fast track' protocol allows patients with high levels of co-morbidity undergoing complex colorectal and reoperative pelvic surgery to benefit from a rapid recovery and early discharge from hospital. The approach is safe and has low readmission rates.

Adolescent↗

PubMed2001

Epidural anesthesia-analgesia shortens length of stay after laparoscopic segmental colectomy for benign pathology.

BACKGROUND: Aggressive postoperative care plans after open colectomy may allow earlier discharge, especially in conjunction with preoperative thoracic epidural anesthesia-analgesia using a local anesthetic and narcotic. The purpose of this study was to evaluate the role of thoracic epidural anesthesia-analgesia using bupivacaine and fentanyl citrate in reducing lengths of stay after laparoscopic colectomy (LAC). METHODS: A consecutive cohort of patients who underwent LAC and who received perioperative thoracic epidural anesthesia-analgesia (TEG) was compared with a standard group of patients (STD) undergoing LAC during the 2 months preceding the implementation of the epidural management protocol. Patients with TEG received 6 to 8 mL bupivacaine (0.25%) and fentanyl citrate (100 microg) through a T8-9 or a T9-10 epidural catheter before the incision was made and a postoperative infusion of bupivacaine (0.1%) and fentanyl citrate (5 microg/mL) at 4 to 6 mL/h for 18 hours. STD patients had supplemental intravenous morphine. The postoperative care plan was otherwise identical between the 2 groups. Patients were matched by sex, age, and type of segmental resection. Discharge criteria included tolerance of 3 general diet meals, passage of flatus or stool, and adequate oral analgesia. Length of stay was defined as the time from admission for the surgical procedure to discharge from the hospital. Statistical analysis included a Student t test, Wilcoxon rank sum test, chi-square trend test, and Fisher exact test where appropriate. Data are presented as mean +/- SEM. RESULTS: Procedures performed were: right hemicolectomy-ileocolectomy (TEG, n = 5; STD, n = 5); or sigmoid colectomy-rectopexy (TEG, n = 17; STD, n = 17). There was no significant difference with respect to operating room (OR) time (TEG, 102 +/- 12 minutes; STD, 87 +/- 17 minutes), body mass index (TEG, 26 +/- 2; STD, 26 +/- 2), or American Society of Anesthesiologists class (I-III) distribution (TEG, 3/12/10; STD, 4/11/7), or mean incision length (TEG, 3.5 +/- 0.4 cm; STD, 3.7 +/- 0.3 cm.) No postoperative complications or readmissions occurred in either group. The length of stay decreased in the TEG group (TEG, 2.8 +/- 0.2 days; STD, 3.9 +/- 0.3; P <.001) and the median length of stay for the 2 groups was similarly less (TEG, 2 days; STD, 3 days). CONCLUSIONS: These data suggest that thoracic epidural anesthesia-analgesia has a significant and favorable impact on dietary tolerance and length of stay after LAC. A thoracic epidural appears to be an important component of a postoperative care protocol, which adds further advantage to LAC without the need for labor-intensive and costly patient care plans.

Analgesia, Epidural↗

PubMed2001

K-ras mutational analysis of polyclonal colorectal cancers identifies uniclonal circulating tumor cells.

The clonal development of colorectal carcinoma resulting from specific mutations in certain oncogenes and/or tumor suppressor genes is a well-accepted model. It is increasingly recognized that a majority of colorectal cancers are polyclonal on the basis of molecular analysis that demonstrates cells with different mutations within a given oncogene or tumor suppressor gene in the same tumor. This polyclonal pattern may occur as a result of either clonal convergence or divergence during the many steps of oncogenesis. Further complicating this picture is the fact that metastatic lesions may arise from only one of the clonal populations within a tumor and thereby present only a partial molecular make-up of the whole tumor. There are few data available that define clonal selection or specificity of circulating tumor cells in patients undergoing curative resection of colorectal carcinoma. The purpose of this paper is to describe the clonal distribution of circulating tumor cells in four patients with multiple K-ras mutations present in the primary lesion. Patients were selected who were known to have polyclonal primary colorectal cancers resected for cure. All patients had multiple mutations present in exon one, codon 12 and/or 13, of the K-ras gene. Blood samples were drawn immediately before surgery and at 2-week to 6-month intervals postoperatively. Epithelial cells were isolated from peripheral blood mononuclear cells using Dynal Immunobeads coated with antiepithelial antibodies. DNA was extracted from these cells and analyzed for all K-ras mutations present in codons 12 and 13 of the patient's primary tumor using allele-specific polymerase chain reaction followed by Microwell Array Diagonal Gel Electrophoresis. Circulating tumor cells were identified in all four patients. However, in each case of positive circulating cells the only mutation identified was an aspartic acid mutation at codon 13. Once positive the circulating tumor cells persisted in subsequent multiple blood samples. These results provide further strength for the theory of polyclonal progression in primary colorectal cancers, although there may be specific mutational patterns that confer the ability to metastasize. The significance of this persistence of the glycine-to-aspartic acid mutation at codon 13 remains to be defined given that none of these patients has clinical evidence of recurrent cancer at the time of this report.

Aspartic Acid↗