Biomedical subjects

V W Fazio

Publications and source records attributed to V W Fazio.

At least 19 recordsLinked to original sources

PubMed2006

Collagenous pouchitis.

Collagenous colitis is characterised by watery diarrhoea, normal colonic mucosa on endoscopy, diffuse colitis with surface epithelial injury, and a distinctive thickening of the subepithelial collagen table on histology. Some patients can develop medically refractory collagenous colitis, in which case they may require surgical intervention. This is the first report of collagenous pouchitis in a collagenous colitis patient with proctocolectomy and ileal pouch-anal anastomosis. A patient with medically refractory collagenous colitis who underwent a total proctocolectomy and ileal pouch-anal anastomosis was sequentially evaluated with an endoscopy and histology of the colon, distal small intestine, and ileal pouch. A 58-year-old female had a 10-year history of collagenous colitis before having a total proctocolectomy and ileal pouch-anal anastomosis for medically refractory disease. The histologic features of collagenous colitis were present in all colon and rectum biopsy or resection specimens, but were absent in the distal ileum specimen. The post-operative course was complicated by persistent increase of stool frequency, abdominal cramps, and incontinence. A pouch endoscopy was performed 3 years after ileal pouch-anal anastomosis which showed the histologic features of collagenous colitis in the ileal pouch, collagenous pouchitis, while the pre-pouch neo-terminal ileum had no pathologic changes. After antibiotic therapy, the histologic changes of collagenous pouchitis resolved. This is the first reported case of collagenous pouchitis. Since the abnormal collagen table and its associated features were only present in the pouch and absent in the neo-terminal ileum, and the patient had histologic improvement after antibiotic therapy, it would suggest that faecal stasis and bacterial load may play a role in the pathogenesis.

Anal Canal↗

PubMed2006

Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection.

BACKGROUND AND METHODS: The comparative benefits and drawbacks of straight coloanal anastomosis (CAA), colonic J-pouch and coloplasty anastomosis after anterior resection are uncertain. Studies published between 1986 and 2005 of colonic J-pouch versus transverse coloplasty or straight CAA were analysed. Endpoints included postoperative complications, and functional and physiological outcomes measured within 6 months, 1 year and 2 years or more after the procedure. A random-effect model was used to aggregate the study endpoints and assess heterogeneity. RESULTS: Thirty-five studies containing 2240 patients (1066 straight CAA, 1050 J-pouch and 124 coloplasty) were included. There was no significant difference in postoperative complications between the three groups. There was a significant reduction in the frequency of defaecation per day by 1.88, 1.35 and 0.74 motions at the three time intervals in the J-pouch group compared with the straight CAA group. Faecal urgency was less prevalent in patients with a J-pouch than those with a straight CAA (odds ratio 0.27 at 6 months or less and 0.21 at 1 year). There was no difference in functional outcome between J-pouch and coloplasty anastomosis. CONCLUSIONS: The colonic J-pouch provided functional benefits over straight anastomosis with no increase in postoperative complications. Coloplasty appeared to have similar benefits but further studies are required for validation.

Anal Canal↗

PubMed2006

Meta-analysis of observational studies of ileorectal versus ileal pouch-anal anastomosis for familial adenomatous polyposis.

BACKGROUND: Surgery for familial adenomatous polyposis (FAP) aims to minimize cancer risk while providing good functional outcome. Colectomy with ileorectal anastomosis and proctocolectomy with ileal pouch-anal anastomosis both offer this, but there is no clear consensus about which is better. METHODS: This is a meta-analysis of comparative studies published between 1991 and 2003 reporting early and late postoperative adverse events, functional outcomes and quality of life. RESULTS: Twelve studies containing 1002 patients (53.4 per cent ileal pouch, 46.6 per cent ileorectal anastomosis) were identified. Bowel frequency (weighted mean difference 1.62 (95 per cent confidence interval (c.i.) 1.05 to 2.20)), night defaecation (odds ratio (OR) 6.64 (95 per cent c.i. 2.99 to 14.74)) and use of incontinence pads (OR 2.72 (95 per cent c.i. 1.02 to 7.23)) were significantly less in the ileorectal group, although faecal urgency was reduced with the ileal pouch (odds ratio 0.43 (95 per cent c.i. 0.23 to 0.80)). Reoperation within 30 days was more common after ileal pouch construction (23.4 versus 11.6 per cent; OR 2.11 (95 per cent c.i. 1.21 to 3.70)). There was no significant difference between the techniques in terms of sexual dysfunction, dietary restriction, or postoperative complications. Rectal cancer was a diagnosis only in the ileorectal group (5.5 per cent). CONCLUSION: Ileal pouch and ileorectal anastomoses have individual merits. Further research is needed to determine which most benefits patients with FAP.

Adenomatous Polyposis Coli↗

PubMed2006

Long-term, health-related, quality of life comparison in patients undergoing single stage vs staged resection for complicated diverticular disease.

OBJECTIVE: To evaluate long-term health-related quality of life, for single-staged and staged resections following reversal, for complicated diverticular disease. PATIENTS AND METHODS: Between 1981 and 2003, 188 patients undergoing single stage (n = 158) or staged resection (n = 30) completed the SF-36 questionnaire. Health-related quality of life (HRQL) was compared between the two groups and the US normal population based on the eight domains of the SF-36. HRQL analysis was also performed at various time intervals. The effect of age and postoperative complications on HRQL was also determined. Functional and postoperative outcomes were also assessed. RESULTS: The single and staged resection groups differed in the presence of comorbidity, degree of peritoneal contamination and operative urgency. No difference in functional outcomes or HRQL was found, even after analysing time-interval subgroups. Social functioning and general health was substantially worse in both groups when compared to US norms. Ageing was found to significantly reduce physical functioning (P < 0.001) and physical and emotional role limitations (P < 0.001 for both). Post-operative complications significantly reduced scores when compared to patients without complications, for physical functioning (63.57 vs 78.7, respectively; P < 0.001), physical role limitation (80.65 vs 86.9, respectively; P < 0.001) and bodily pain (66.67 vs 74.81, respectively; P < 0.01). CONCLUSIONS: No significant difference in long-term HRQL was found in patients undergoing single staged or staged resection for complicated diverticular disease. There was significant impact of ageing and postoperative complications on physical health. Prospective studies that include pre-operative data on HRQL are required to compare the two operative techniques, with emphasis on quality of life of patients left with a permanent stoma.

Age Factors↗

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

Maintenance therapy with a probiotic in antibiotic-dependent pouchitis: experience in clinical practice.

BACKGROUND: Management of antibiotic-dependent pouchitis is often challenging. Oral bacteriotherapy with probiotics (such as VSL #3) as maintenance treatment has been shown to be effective in relapsing pouchitis in European trials. However, this agent has not been studied in the US, and its applicability in routine clinical practice has not been evaluated. AIM: To determine compliance and efficacy of probiotic treatment in patients with antibiotic-dependent pouchitis. METHODS: Thirty-one patients with antibiotic-dependent pouchitis were studied. VSL #3 is a patented probiotic preparation of live freeze-dried bacteria. All patients received 2 weeks of ciprofloxacin 500 mg b.d. followed by VSL #3 6 g/day for 8 months. Baseline Pouchitis Disease Activity Index scores were calculated. Patients' symptoms were reassessed at week 3 when VSL #3 therapy was initiated and at the end of the 8-month trial. Some patients underwent repeat pouch endoscopy at the end of the trial. RESULTS: All 31 patients responded to the 2-week ciprofloxacin trial with resolution of symptoms and they were subsequently treated with VSL #3. The mean duration of follow-up was 14.5+/-5.3 months (range: 8-26 months). At the 8-month follow-up, six patients were still on VSL #3 therapy, and the remaining 25 patients had discontinued the therapy due to either recurrence of symptoms while on treatment or development of adverse effects. All six patients who completed the 8-month course with a mean treatment period of 14.3+/-7.2 months (range: 8-26 months) had repeat clinical and endoscopic evaluation as out-patients. At the end of 8 months, these six patients had a mean Pouchitis Disease Activity Index symptom score of 0.33+/-0.52 and a mean Pouchitis Disease Activity Index endoscopy score of 1.83+/-1.72, which was not statistically different from the baseline Pouchitis Disease Activity Index endoscopy score of 2.83+/-1.17 (P=0.27). CONCLUSION: This study was conducted to evaluate bacteriotherapy in routine care. The use of probiotics has been adopted as part of our routine clinical practice with only anecdotal evidence of efficacy. Our review of patient outcome from the treatment placebo showed that only a minority of patients with antibiotic-dependent pouchitis remained on the probiotic therapy and in symptomatic remission after 8 months.

Adult↗

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↗

PubMed2005

Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy.

INTRODUCTION: Pouch-related fistula occurs in 5-10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas. METHODS: Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch-perineal, pouch-abdominal wall and pouch-vaginal fistula during follow-up. RESULTS: Median patient follow-up was 4.1 (range 0-19) years. By 15 years' follow-up, pouch-vaginal fistulas had occurred in 44 women (5.2 per cent). The prevalence of ileal pouch-perineal and pouch-abdominal wall fistula was 3.6 per cent (70 patients) and 1.5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1.28 (95 per cent confidence interval (c.i.) 1.00 to 1.65) and 1.73 (95 per cent c.i. 1.07 to 3.48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3.43 (95 per cent c.i. 2.43 to 4.84) and 4.02 (95 per cent c.i. 1.27 to 12.77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4.29 (95 per cent c.i. 2.33 to 7.91)), patient sex (HR 0.74 (95 per cent c.i. 0.58 to 0.95) for men versus women) and pelvic sepsis (HR 3.79 (95 per cent c.i. 2.48 to 5.79)). CONCLUSION: This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula.

Abdominal Wall↗

PubMed2005

Comparison of cecal abrasion and multiple-abrasion models in generating intra-abdominal adhesions for animal studies.

BACKGROUND: The formation of postoperative adhesions is a common problem in abdominal surgery that may lead to serious complications. Appropriate animal adhesion models are essential for the investigation of adhesiogenesis and the development of new anti-adhesive products. Although animal models have been developed to study the process of adhesion formation in the abdomen, they are not effective in generating adhesions located over small bowel where adhesions are most commonly observed in clinical practice. METHODS: Twenty-nine Sprague Dawley rats were subjected to standardized cecal abrasion (group 1; n=9), or two types of multiple abrasion, in which cecal and 3 or 5 abrasions were performed on small bowel (group 2, n=10; and group 3, n=10). An observer blinded to the randomization assessed the difficulty of adhesiolysis on a 6-point scale, and the locations of the adhesions were recorded 21 days after the initial surgery. RESULTS: Adhesiolysis was significantly more difficult in group 3 than in group 1 (p=0.01). The number of animals that had adhesions between the small bowel segments and the total number of locations where small bowel adhered were significantly greater in group 2 and 3 than in group 1 (p<0.05 for all comparisons). CONCLUSIONS: Abrasions to the small bowel created consistent adhesions that have clinical characteristics of intra-abdominal adhesions as compared to the standard cecal abrasion model and that can be used in future animal studies on adhesions.

Animals↗

PubMed2005

Management of peristomal pyoderma gangrenosum.

PURPOSE: This study was designed to evaluate the presentation, management, and outcome of peristomal pyoderma gangrenosum at a specialist colorectal unit and develop a strategy for therapy. METHODS: Patients with peristomal pyoderma gangrenosum were identified from a prospectively accrued Institutional Review Board-approved stoma database. Data were collected regarding demographics, disease status, history of illness, time to healing, and treatments used from the database and by chart review. RESULTS: Sixteen patients presented between 1997 and 2002 with peristomal ulceration consistent with a diagnosis of peristomal pyoderma gangrenosum. Diagnosis was predominantly clinically based on a classic presentation of painful, undermined peristomal ulceration. The underlying diagnosis was Crohn's disease in 11 patients, ulcerative colitis in 3, indeterminate colitis in 1, and posterior urethral valves in 1. At the time of development of peristomal pyoderma gangrenosum, the underlying disease was active in 69 percent of patients. Stoma care, ulcer debridement with unroofing of undermined edges, and intralesional corticosteroid injection was associated with a 40 percent complete response rate and further 40 percent partial response rate. Of five patients who received infliximab, four (80 percent) responded to therapy. Complete response after all forms of therapy, including stoma relocation in seven patients, was 87 percent. CONCLUSIONS: Local wound management and enterostomal therapy are extremely important for patients with peristomal pyoderma gangrenosum. Infliximab may provide a useful option for those failing other forms of medical therapy. Relocation of the stoma is reserved for persistent ulceration failing other therapies, because peristomal pyoderma gangrenosum may recur at the new stoma site.

Adrenal Cortex Hormones↗

PubMed2005

Male sexual function improves after ileal pouch anal anastomosis.

PURPOSE: Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis. However sexual functional disturbances after this procedure can be a concern for patients. Therefore the aim of this study was to determine the outcome of sexual-function related quality of life in male patients undergoing restorative proctocolectomy. METHODS: One hundred and twenty-two male patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis between 1995 and 2000 were evaluated by the validated International Index of Erectile Function (IIEF) scoring instrument. This index scale examines sexual function in five categories. These are erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. The IIEF instrument was administered after surgery and then scores before and after RP/IPAA were evaluated and compared. The significance of age at the time of the surgery, type of surgery, type of anastomotic technique (mucosectomy vs stapled) and septic complications on sexual functional outcome were also investigated. RESULTS: Mean age at the time of the surgery was 39.9 +/- 11.5 years. The mean follow-up period (time between pouch surgery and IIEF completed) was 3.6 +/- 1.8 years. There was statistically significant improvement in 4 of 5 categories of sexual function (erectile function, sexual desire, intercourse satisfaction, and overall satisfaction) where patients had improved scores after surgery compared to prior to surgery. The mean erectile function score increased pre to post surgery by 2.12 points (P = 0.02), which indicates better sexual results. Anastomotic technique and septic complication did not influence the results, however, older age had a negative impact on results. CONCLUSIONS: Despite some adverse sexual functions, male patients who undergo RP/IPAA for the surgical management of their colitis may preserve or improve their overall sexual functional outcome.

Adult↗

PubMed2004

Significance of incidental desmoids identified during surgery for familial adenomatous polyposis.

PURPOSE: The behavior of intra-abdominal desmoids in familial adenomatous polyposis is incompletely understood. Findings range from typical mass lesions to flat sheets, termed the desmoid reaction or desmoid precursor lesion. The latter often are incidental findings of uncertain significance. The study was designed to describe the natural history of incidental intra-abdominal desmoid tumors with particular reference to the desmoid reaction. METHODS: Patients who underwent laparotomy for familial adenomatous polyposis at the Cleveland Clinic Foundation were identified. The incidence of incidental intra-abdominal desmoid tumors was determined by review of operative records. Intra-abdominal desmoid tumors were classified as mass lesions if three-dimensional or desmoid reaction if two-dimensional. The incidence of clinically apparent intra-abdominal desmoid tumors (typical mass lesions on physical examination or cross-sectional imaging in symptomatic patients) was determined by chart review. The incidence of clinical intra-abdominal desmoid tumors between groups was compared by Fisher's exact test. RESULTS: A total of 266 patients (153 females; median age, 26 (range, 9-63) years) underwent abdominal surgery for familial adenomatous polyposis. Incidental intra-abdominal desmoid tumors were identified in 34 patients: 8 at the index surgery and 26 at relaparotomy. These lesions influenced the planned procedure in eight cases (26 percent), including preventing ileoanal pouch in 3 of 19 patients in whom this was intended. The median follow-up from the time of identification of intra-abdominal desmoids was 42 (range, 2-178) months at which point four patients (11 percent) had developed clinical intra-abdominal desmoid tumors. There was no significant difference in incidence of clinical intra-abdominal desmoid tumors between mass and desmoid reaction groups ( P = 0.27). CONCLUSIONS: Incidental intra-abdominal desmoid tumors are a common finding at relaparotomy in patients with familial adenomatous polyposis. These lesions influence planned surgery in a minority of cases. Desmoid reaction may have little bearing on the subsequent development of clinically significant intra-abdominal desmoid tumors.

Adenomatous Polyposis Coli↗

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

Benefits of 'clean sweep' in Peutz-Jeghers patients.

OBJECTIVE: Laparotomy is the treatment of choice in Peutz-Jeghers Syndrome (PJS) patients for endoscopically irretrievable symptomatic polyps and polyp-related complications. During the last decade, we have operated on majority of the PJS patients with the purpose of removing all the gastrointestinal polyps (clean sweep), when an operation was indicated. The aim of this study is to evaluate the effect of clean sweep technique on the need for repeated surgery compared to a problem focused approach. PATIENTS AND METHODS: All patients with PJS treated in our institution since 1964 were studied. They were placed into two groups; those who had a problem-focused operation and those who were operated with the purpose of removing all small and large intestinal polyps. Demographics, presentation, follow-up period and the need for recurrent surgery were compared. RESULTS: We identified 11 patients (4 males, 7 females). Eight patients (5 females; median age 18.5) had problem-focused surgery for bleeding-anaemia (n = 3) or obstruction-intussusception (n = 5). These patients required 23 further operations within 87 patient-follow-up-years (2.64 operations per 10 years). Three patients (2 females; median age 6) were operated for bleeding-anaemia (n = 1) or obstruction-intussusception (n = 2) using the 'clean sweep' approach. These patients did not require any further surgery within 21 patient-follow-up-years. The gender, presentation and follow-up periods were similar between the groups. However, the 'clean sweep' technique appears to have reduced the need for further operations when it is compared with problem-focused approach (P = 0.01). CONCLUSION: To reduce the need for abdominal surgery and consequent problems in PJS patients, an attempt to remove all detected polyps (clean sweep technique) may be beneficial in these patients.

Adolescent↗

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↗

PubMed2003

Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis.

INTRODUCTION: Ileal pouch-anal anastomosis (IPAA) for indeterminate colitis (IndC) may lead to an increased risk of perineal complications and pouch loss. This study evaluated pathological subgroups of IndC to identify a predictor of increased complication rates after IPAA for IndC. PATIENTS AND METHODS: Of 171 IPAAs with a postoperative diagnosis of IndC, IndC was confirmed in 115 of the 140 specimens available for re-examination. These were divided into IndC favouring ulcerative colitis (Group I; n = 99), 'true' IndC (Group II; n = 8), and IndC favouring Crohn's (Group III; n = 8). 61 presented with fulminant colitis. Patients in Group I were subdivided into having (A) deep ulcers (B) transmural lymphoid aggregates (C) skip lesions (D) terminal ileal inflammation and/or (E) a caecal patch. Outcome was determined by chart analysis, and compared to 231 randomly selected patients with IPAA for ulcerative colitis (UC) matched for age, gender, and follow-up. RESULTS: Only patients with evidence of deep ulceration (Group IA) had a significant increase in the incidence of Crohn's disease (4.3%vs. 0.43%, P = 0.04), complex perianal fistulae (4.3%vs. 0.43%, P = 0.04), and pelvic abscess (12.9%vs. 2.2%, P < 0.001). No pathological subgroup of IndC patients had a significantly different rate of pouch failure or pouch loss. CONCLUSIONS: Pathological stratification may predict those more likely to develop Crohn's disease or other complications, but not pouch failure. On this basis, we feel that patients with IndC should not be precluded from having IPAA surgery.

Anastomosis, Surgical↗