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PubMed1996

Prophylactic colectomy in patients with hereditary nonpolyposis colorectal cancer.

Prophylactic colectomy is indicated in patients whose colons are at very high risk of developing cancer. Familial adenomatous polyposis (FAP) is the best example of a situation where prophylactic surgery is clearly necessary to prevent cancer, and has been shown to be effective in doing so. Recent advances in the molecular genetics of colorectal cancer have allowed presymptomatic diagnosis of patients with another dominantly inherited syndrome, hereditary nonpolyposis colorectal cancer (HNPCC). Prior to this, prophylactic colectomy had not been a consideration for patients in HNPCC families. A review of the outcome of colectomy and ileorectal anastomosis in FAP patients shows that although it is a major abdominal surgery there is a relatively low complication rate and the functional outcome is acceptable for a prophylactic procedure. The decision to apply colectomy to HNPCC patients depends on careful consideration of factors such as comorbidity, age, sphincter function, likely compliance with future surveillance and likely efficiency of colonoscopy as a cancer prevention strategy. In general, prophylactic colectomy is indicated in HNPCC gene carriers, because their lifetime risk for colorectal cancer is 80%.

Adenomatous Polyposis Coli↗

PubMed2000

Benefits of laparoscopic-assisted colectomy for colon polyps: a case-matched series.

OBJECTIVE: To clarify the true benefits of laparoscopic-assisted colectomy by comparing clinical outcomes from a series of laparoscopic right colectomies with matched open colectomies, all performed for the singular indication of polyp not amenable to colonoscopic removal. PATIENTS AND METHODS: A retrospective case-matched study was performed of consecutive patients undergoing laparoscopic-assisted right hemicolectomy for polyps between January 1992 and July 1997. Each case was matched to a control undergoing the equivalent open procedure for the same indication during the same time period. RESULTS: Thirty-eight patients undergoing laparoscopic-assisted right hemicolectomy for polyps were identified, and matches were found. The conversion rate was 18.4% (7/38), 21.4% early in the series and 10% in later experience. Operative times were longer for laparoscopic-associated colectomy (median, 208 minutes vs 150 minutes, P < .001). Laparoscopic-assisted colectomy resulted in shorter postoperative ileus (time to flatus, 3.0 vs 4.0 days, P < .001; time to bowel movement, 3.5 vs 5.0 days, P < .001) and in earlier tolerance of regular diet (3.5 vs 6.0 days, P < .001). Fewer days of narcotic administration were required by the laparoscopic group (3.0 vs 4.5 days, P < .001). This resulted in a significantly shorter length of hospital stay (4.0 vs 7.0 days, P < .001). There was no significant difference in the incidence of postoperative complications. CONCLUSIONS: Laparoscopic right hemicolectomy has significant patient benefits. These benefits are apparent when procedures of equal complexity and equivalent indications are compared. Laparoscopic-assisted resection has become our preferred approach for polyps not amenable to colonoscopic polypectomy.

Aged↗

PubMedDate not supplied

Factors influencing bowel function after low anterior resection and sigmoid colectomy.

BACKGROUND/AIMS: The aim of this study was to evaluate the subjective bowel function after low anterior resection and sigmoid colectomy and to clarify the clinicopathologic factors influencing postoperative bowel habits. METHODOLOGY: Eighty-six patients who underwent low anterior resection and sigmoid colectomy replied to the questionnaire which consisted of 8 categories of bowel symptoms. The patients were divided into 2 groups: good bowel function showing less than half of symptoms (< 4) and poor bowel function showing more than half of symptoms (> or = 4). RESULTS: After low anterior resection, patients were often complicated with incomplete evacuation (75%), bowel movement at night (60%), defecation more than twice a day (46%), and soiling (27%). The mean number of defecation/day and frequency of patients with night stools was significantly higher after low anterior resection than sigmoid colectomy (2.81 vs. 2.18, P < 0.05; and 60% vs. 29%, P < 0.05). Poor bowel function after low anterior resection was frequent in patients with high ligation of the inferior mesenteric artery (82%, P < 0.05), injury to the pelvic autonomic nerve (82%, P < 0.05), and blood transfusion; while poor bowel function after sigmoid colectomy was frequent in patients with resected colon measuring 25 cm or more (81%, P < 0.05). CONCLUSIONS: These results indicate that poor bowel function after low anterior resection is associated with high ligation of the inferior mesenteric artery and injury to the pelvic autonomic nerve; while poor bowel function after sigmoid colectomy correlates with length of the resected colon. Less aggressive surgery is needed to preserve good bowel function.

Aged↗

PubMed2000

A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis.

Laparoscopic sigmoid colectomy (LSC) for diverticular disease accounts for a limited number of laparoscopic colon cases performed nationally because of the technical challenge it presents. Our objective was to determine the feasibility and impact of the laparoscopic approach in elective sigmoid colectomy for diverticular disease and to compare these results with those of the open approach. Twenty elective laparoscopic sigmoid colectomies (LSCs) were performed for diverticulitis between April 1992 and July 1999 at a university-affiliated urban hospital. A case-control study was performed comparing LCS with a matched control group of conventional open sigmoidectomies. Fourteen of 20 sigmoidectomies were successfully completed laparoscopically. The mean operative time for LSC was similar to that for open sigmoid colectomy (251 vs 243 minutes). There was earlier return to oral intake in the LSC group (1 vs 5 days; P < 0.001). The mean length of stay was significantly shorter (P = 0.029) in LSC (4.8 days) versus open sigmoid colectomy (7.8 days). Conversion to open sigmoidectomy extended hospital stay to 8.16 days. The overall complication rate was 10 per cent in both groups. We conclude that LSC can be performed effectively and with a low complication rate for diverticular disease. LSC provides the benefit of quicker return of bowel function and shorter hospitalization.

Adult↗

PubMed2002

The natural history diverticular disease: is there a role for elective colectomy?

BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications. MATERIALS AND METHODS: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients. RESULTS: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications. CONCLUSIONS: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.

Colectomy↗

PubMedDate not supplied

[The segmentary colectomy or the left hemicolectomy for sigmoid cancer].

UNLABELLED: The aim of this study was to show the benefits of segmentary colectomy (Raybard) for tumors located on sigmoid colon. A retrospective study was carried on 90 observations performed in the III-rd Surgery Clinic, Iaşi between 1994 and 1998. Types of surgery performed were: left hemicolectomy (7 observation); segmentary colectomy (54 observation); left lower colectomy (17 observation); Hartmann operation (12 observation). CONCLUSIONS: This analysis showed the same survival for segmentary colectomy and left hemicolectomy. We consider segmentary colectomy the basic operation for this type of cancer.

Carcinoma↗

PubMed1992

Changes in rectal epithelial cell proliferation and intestinal bile acids after subtotal colectomy in familial adenomatous polyposis.

Subtotal colectomy and ileorectal anastomosis in familial adenomatous polyposis patients can induce temporary regression of adenomas in the rectum. The mechanism for this phenomenon is unclear. We evaluated the effect of colectomy on rectal mucosal proliferation, in relation to changes in bile acid metabolism. Four familial adenomatous polyposis patients were studied before and 3-6 months after surgery, and eight others 7-22 years postoperatively. Within 6 months after surgery, the size of the proliferative zone of the colonic crypts was found to be reduced (P less than 0.05). The proliferative activity of total colonic crypts was not affected within this period. More than 7 years postoperatively, increased cell proliferation of total crypts (P less than 0.02), as well as mid (P less than 0.05) and basal (P less than 0.05) crypt compartments, were observed compared to shortly after colectomy. In duodenal bile, deoxycholic acid was absent shortly after operation, whereas several years after operation only a small fraction (2%) was present. Fecal secondary bile acid excretion diminished after colectomy and did not change several years postoperatively. In postoperative stools only, small proportions of ursocholic and ursodeoxycholic acids (about 5% each) were consistently found. As subtotal colectomy causes a temporary decrease in the length of the proliferative zone of rectal crypts toward a normal pattern, this may explain regression of rectal polyps. This temporary effect may be mediated, at least in part, by decreased amounts of cytotoxic secondary bile acids in the rectal lumen.

Adenomatous Polyposis Coli↗

PubMedDate not supplied

Laparoscopic colectomy in the management of large, sessile, transformed colorectal polyps.

BACKGROUND: Colonic polyps are usually removed endoscopically. Surgical intervention is reserved for large, inaccessible colorectal polyps that have underdone malignant transformation. Laparoscopic management of colonic polyps has gained a well-defined role. METHODS: Since 1993, 650 laparoscopic colectomies have been performed in our department. Twenty-eight patients with large, sessile, polyps that have undergone malignant transformation underwent elective laparoscopic colectomy. Operative procedures included 14 sigmoidectomies, 10 low anterior recto-sigmoid resections, 3 right colectomies, and 1 left colectomy. Central ligation of vessels and lymph node dissection were preformed in all patients. RESULTS: The main outcome measures include conversion rate (11%), morbidity (11%), and mortality (3.5%). The mean return of bowel function was 3.1 days, liquid intake 1.4 days, solid food intake 2.5 days, and mean hospital stay 8 days. The mean specimen length was 23 cm, and the mean number of retrieved lymph nodes was 15. Malignancy according to Dukes classification was in situ, n=4; A, n=15; B, n=4; C, n=4; and D, n=1. During follow-up, 2 patients developed liver metastases. CONCLUSION: Laparoscopic colectomy is a technically feasible and effective method for treating large colorectal polyps that have undergone malignant transformation.

Aged↗

PubMed1991

[Results and late sequelae of colectomy].

Results after 55 colectomies are reported in the period from 1962-1986. The surgical intervention was indicated by ulcerative colitis in 19, Crohn's disease in 18 and familial polyposis of the colon in 18 cases. 37 total colectomies, 12 subtotal colectomies with ileorectal anastomosis and 6 colectomies with a remaining terminal closed stump of the rectum were performed. During the period of observation postoperative lethality decreased from 37% to 6%. Death was most frequently caused by thromboemboli and peritonitis. In 44% of the patients ill with familial polyposis malignant degeneration could be observed. 3 died by generalized metastases. Metabolism of protein, lipid and electrolyte showed no essential disturbances after colectomy. Intestinal assimilation was nearly standard. More difficult is social reintegration.

Adenomatous Polyposis Coli↗

PubMed1983

[Mucosal hyperplasia of the ileum after subtotal colectomy in rats].

To evaluate factors contributing to ileal mucosal hyperplasia following extensive colectomy, the following three models were designed in rats: Subtotal colectomy and end-to-end ileoproctostomy; retransection of the terminal ileum with end-to-side proximal-ileoproctostomy (colectomy group), End-to-side ileoproctostomy without colectomy (bypass group), and End-to-side ileocecostomy (control group). In all groups the terminal ileum was left out of the intestinal stream as defunctionalized segments. Specimens were obtained from the terminal ileum during operation and from both the functioning and the defunctionalized segments at various intervals postoperatively. The mucosal hyperplasia was evaluated by measuring eight variables including numbers of villi around the bowel circumference, villous height, crypt depth, total mucosal thickness, epithelial cell counts per villus, DNA contents per unit length of the bowel and radioactivity of incorporated 3H-thymidine as well as DNA specific activity. The results showed that marked mucosal hyperplasia of the functioning segments was noted in all groups, and that mucosal hyperplasia was also observed in defunctionalized segments of colectomized rats, but not in those of both bypass rats and control. These findings were statistically confirmed by analysis of variance. It was concluded that although intraluminal factors played an important role in mucosal hyperplasia of the ileum following extensive colectomy, humoral factors might be also involved in intestinal adaptation.

Animals↗

PubMed1981

Effect of colectomy upon ammonemia and glutaminemia in rats with stricture of the portal vein.

Current theories on the pathogenesis of hepatic encephalopathy indicate that intestinal bacteria produce cerebral toxins, such as ammonia; colectomy has been proposed in the treatment of chronic portal systemic encephalopathy. This study was undertaken to evaluate the evolution of ammonemia and glutaminemia during a four month period in rats after a colectomy, with and without portal vein stricture. Groups of nine rats were studied: group 1 served as control study, total colectomy was performed on the rats in groups 2 and 3, but a gradual stricture of the portal vein was produced in the rats of group 3 and group 4 that had not had a colectomy. The ammonia levels were stable in groups 1 and 2, 48 +/- 2 milligrams per 100 milliliters; in group 3, ammonia levels rose significantly one week after portal vein stricture, 136 +/- 10, and decreased progressively until the end of the first month, 70 +/- 10, although in group 4 of the ammonia level always remained higher than in this one. The levels of glutamine decreased after colectomy in group 2 and rose markedly in both groups 3 and 4 during the first week but persisted at the same level only in group 4. These data confirm the importance of hepatic clearing of portal blood in ammonia and glutamine metabolism and underline the importance of the colon as the main, but not exclusive, site of splanchnic ammonia and glutamine production. The improvement in hepatic encephalopathy observed after removal of the colon may be due to the reduced output of these two substances.

Ammonia↗

PubMed1994

Laparoscopic colectomy: at what cost?

The purpose of this study was to compare laparoscopic to open colectomy with respect to: 1) morbidity and mortality, 2) adequacy of resection for cancer (margins and number of nodes), 3) operative time, 4) postoperative time for tolerating diet and discharge, and 5) total hospital charges. A historical control group of open colon surgery patients was used. Laparoscopic colectomy was completed in 18/24 patients and 6 were converted to open colectomy. There were no operative or perioperative mortalities. In procedures for cancer, all margins were free of tumor. The average number of nodes in the laparoscopic group (LC) was higher than in open colectomy (OC) group. The average operative time was slightly longer in the LC group compared to the OC group. Postoperative length of stay was shorter in the LC group, and considerably shorter in the elective LC group. Corrected average total hospital cost was lower in the LC group than in the OC group. Laparoscopic colectomy has acceptable morbidity and mortality, is cost-efficient and seems to provide adequate resection for cancer, although long-term data will be crucial to this issue.

Adult↗

PubMed1998

Segmental colectomy in the management of colonic inertia.

Subtotal colectomy with ileorectostomy has been proposed for the management of colon inertia-type constipation. However, many patients experience frequent bowel movements, watery diarrhea, or both after such a treatment. The purpose of this study is to determine the proper colectomy with which to treat colon dysmotility constipation without the negative side effects of frequent bowel movements, watery diarrhea, or both. Forty idiopathic constipation patients were studied. All of the patients showed a prolonged right or left colon transit time and normal transit time of the sigmoid and rectum. They received different types of colectomies (left, right, and subtotal) according to the distribution or accumulation of markers in the colon. Within 3 months of surgery, all of the patients experienced a dramatic improvement of their symptoms without frequent bowel movements or watery diarrhea. No significant complications developed after surgery. All the patients were followed up for at least 2 years. Most of them (37 cases) still had satisfactory bowel movements and no other constipation symptoms. However, 3 of the 40 cases developed symptoms of constipation 1 1/2 to 2 years after surgery. They all received subtotal colectomy with ileorectal anastomosis subsequently. They reobtained satisfactory bowel movements and experienced a subsidence of other constipation symptoms 3 months later. These results suggest that directed segmental colectomy can improve colonic inertia constipation without the consequence of frequent bowel movements and diarrhea.

Adult↗

PubMed1994

Adequacy of lymphadenectomy in laparoscopic-assisted colectomy for colorectal cancer: a preliminary report.

The hypothesis that the length of bowel and amount of mesentery resected with laparoscopically assisted colectomy are comparable to traditional open techniques was tested by means of a chart review of prospectively collected data of 22 laparoscopically assisted colectomies, 35 open colectomies performed by the same surgeon, and 39 other open colectomies performed at the same institution by other community surgeons. The average length of bowel resected in the laparoscopically assisted group was 21.7 cm, for the traditionally resected group, 31.4 cm, and for the other group, 26.7 cm. No statistically significant differences existed between the three evaluable groups. Although there was a trend toward greater length of bowel resected with the open technique, there was no statistically significant difference in this study. Follow-up at a mean of 24 months after resections shows no abdominal wall recurrences or any unusual patterns of recurrence. It is concluded that laparoscopically assisted colectomy can be performed in select groups to obtain adequate surgical resection for colorectal carcinoma. Further studies to generate larger numbers of patients with longer follow-up to determine the adequacy of resection as well as the comparability of cure rate will be necessary to confirm the findings of this preliminary study.

Aged↗

PubMed2006

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease.

BACKGROUND: There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD). METHODS: A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: 7 months. RESULTS: From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the <or= 3 month group compared to the other groups. There was no significant difference in the overall incidence of postoperative complications among the 3 groups. Postoperative fistulas were significantly more common after RPC in Groups 1 and 2 as compared to Group 3. CONCLUSION: Restorative proctocolectomy performed within 3 months after the initial subtotal colectomy was associated with a significant increase in the incidence of intra-operative complications. Although this increase was not statistically significant, there was a significantly higher incidence of fistula formation when RPC was undertaken at up to 7 months after the subtotal colectomy for IBD. Thus, if possible, early RPC after subtotal colectomy should be discouraged.

Adult↗

PubMed1999

Laparoscopic colectomy: indications for conversion to laparotomy.

HYPOTHESIS: Although experience with laparoscopic colectomy continues to accumulate, criteria for patient selection for the procedure have yet to be developed. We propose that review of indications for conversion to laparotomy during laparoscopic colectomy should define some of the current technical limitations of the procedure. This information may facilitate development of selection criteria for laparoscopic colon and rectal surgery. DESIGN: Single-institution retrospective medical records review. SETTING: Tertiary referral center. PATIENTS: Two hundred patients who underwent laparoscopic colon surgery, in 47 (23.5%) of whom the procedure was converted to laparotomy. INTERVENTIONS: A registry of 200 patients who have undergone laparoscopic colon surgery was analyzed. Medical records of 47 patients whose procedure was converted were reviewed to assess indications for conversion and identify factors contributing to the need for conversion. RESULTS: Between July 1, 1991, and September 30, 1998, 200 laparoscopic colon procedures were performed: 78 ascending colectomies, 74 descending or sigmoid colectomies, 14 diverting stomas, and 34 "other procedures." The 200 patients were divided into 4 cohorts of 50 consecutive patients to analyze changes with time. The conversion rate was statistically greater in the first quarter (18 patients [36.0%]) than in subsequent quarters (16.0%; P <.05). The rate of conversion to laparotomy for segmental resection of the ascending and descending colon (31/153 [20.3%]) has been equivalent and less than the conversion rate for other procedures (16/33 [48.5%]; P <.05). The distribution of patients by operative indication has been fairly constant. The indication for operation has not influenced the need for conversion. The indications for conversion were technical problems in 15 patients (hypercarbia, unclear anatomy, and stapler misfire), laparoscopic complications in 9 patients (bleeding, cystotomy, and enterotomy), and problems that exceeded the limits of laparoscopic dissection in 23 patients (phlegmon, adhesions, obesity, and adjacent organ involvement by cancer). CONCLUSIONS: Our conversion rate has decreased during our experience, and currently the need for conversion to laparotomy is most frequently caused by situations such as excessive tumor bulk, adhesions, and diverticular phlegmon that exceed the technical limitations of laparoscopic dissection. Colorectal reanastomosis following a Hartmann resection and procedures involving resection of the distal rectum are unlikely to be successfully completed. Although obesity accentuates the technical limitations of laparoscopic dissection, it is an infrequent cause for conversion to laparotomy.

Colectomy↗

PubMed1988

Treatment of Crohn's colitis. Segmental or total colectomy?

In our institution, segmental Crohn's colitis has been treated with segmental colectomy rather than more extensive resection. The purpose of this study was to review the rate of recurrence following surgical treatment of Crohn's colitis using this approach. From 1974 through 1984, 37 patients with Crohn's disease limited to the colon or rectum underwent resection. Average time of follow-up was 5.5 years. There were recurrences in 13 (62%) of 21 patients treated by segmental colectomy and four (67%) of six patients treated by total abdominal colectomy and small-bowel recurrences in two (20%) of ten patients treated by proctocolectomy. Intestinal continuity was maintained in 17 (81%) of the 21 patients treated by segmental resection. Although recurrence is likely, segmental colectomy improves the quality of life by delaying the need for a stoma and by preserving functioning bowel.

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↗